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How to convince patients to take their medicines 


10 things to know about neuropathic pain page 23 

Ask the experts at the ^ 
C+D Conference vv v 

Your chance to quiz the biggest brains in the industry at the largest pharmacy conference of the year 

The C+D Conference 

at the Pharmacy Show 
NEC Birmingham 10-11 October 201 

The C+D Senate Live 

The community pharmacy 


Nurofen Plus provides significantly 
greater pain relief* than paracetamol 
+ codeine + caffeine 1 

Why Nurofen Plus? If you were pain, you'd be scared too - in a pain 
relief study* 72% of customers preferred ibuprofen + codeine (Nurofen Plus) 
to a paracetamol + codeine + caffeine combination product.' 

So give pain a fright and your pain customers what they prefer, recommend 
Nurofen Plus because there's no more effective painkiller available 
without prescription. 

* In a dental pain study 

Essential Information Nurofen Plus Tablets contains 200mg ibuprofen and 12.8mg Codeine phosphate Indications: For the short term treatment of acute, moderate pain (such as 
rheumatic and muscular pain, backache, migraine, headache, neuralgia, period pain and dental pain) when other painkillers have not worked. Dosage and Administration: For oral 
administration and short-term use only. Adults. 1 or 2 tablets every 4 to 6 hours. At least four hours between doses. No more than 6 capsules in any 24 hour period. Not to be taken 
for more than 3 days continuously. The patient must consult a doctor if symptoms persist or worsen, or if the product is required for more than 3 days. Not to be taken less than 4 
hours after taking other painkillers. The Elderly: No special dosage modifications are required for elderly patients, unless renal or hepatic function is impaired, in which case dosage 
should be assessed individually. Not for use by children under 12 years of age. Contraindications: Hypersensitivity to ibuprofen or other constituent. History of hypersensitivity reactions 
(e.g. asthma, rhinitis, angioedema, or urticaria) in response to aspirin or other non-steroidal anti-inflammatory drugs. History of, or existing gastrointestinal ulceration/perforation 
or bleeding. Severe hepatic failure, severe renal failure or severe heart failure. In last trimester of pregnancy there is risk of premature closure of the foetal ductus arteriosus. 
Onset of labour may be delayed and the duration increased with increased bleeding tendency in both mother and child. Hypersensitivity to codeine, respiratory depression, chronic 
constipation Precautions and Warnings: Caution in patients with certain conditions, which may be made worse, e.g. systemic lupus erythematosus and mixed connective tissue disease, 
gastrointestinal disorders and chronic inflammatory intestinal disease, hypertension and/or cardiac impairment, renal impairment, hepatic dysfunction. The elderly are at increased 
risk of the consequence of adverse reactions. Bronchospasm may be precipitated in patients with bronchial asthma or allergic disease. Do not use with other NSAIDs, including COX-2 

For three days use only. Can cause addiction. 




specific inhibitors. Female fertility may be impaired by a reversible effect on ovulation. Gl bleeding, ulceration or perforation Caution is required in patients on medications which 
increase the risk of gastrotoxicity or bleeding. If Gl bleeding or ulceration occurs, stop treatment and refer to a doctor. If mucosal lesion, skin rash or other sign of hypersensitivity o 
the treatment must be stopped. This medicine contains codeine which can cause addiction if you take it continuously for more than 3 days. If you 'or headaches 

for more than 3 days it can make them worse Side Effects: Hypersensitivity reactions may include non-specific allergic reactions, anaphylaxis, res| 'act reactivity (e.g. asthma, 

bronchospasm) and various skin reactions (e.g. pruritus, urticaria, angioedema). Side effects to codeine include constipation, respiratory depression, cough suppression, nausea and 
drowsiness. Regular prolonged use of codeine is known to lead to addiction and symptoms of restlessness and irritability may result when treatment is then stopped MRRP (excl VAT): 
£2.36 (12 tablets) £4.44 (24 tablets) £5.28 (32 tablets) Legal Category: P. Product Licence Numbers: PL 000327/0082 Licence Holder: Crookes Healthcare Limited, Nottingham NG2 3AA. 
Date of Preparation: March 2010 References 1 McQuay et al. Anaesthesia 1992;47:672-677. 

Adverse events should be reported. Reporting fo 
Adverse events should be rep. 

"The little difference that 
makes a big difference." 

Product Information. Panadol Advance 500mg Tablets. Presentation: Paracetamol 500 mg. Contains 
disintegrant system to accelerate dissolution. Uses: Mild analgesic and antipyretic. Headache, migraine, 
tension headache, toothache, backache, rheumatic and muscle pain, dysmenorrhoea. sore throat, 
feverishness, aches and pains of cold and flu, pain due to non-serious arthritis. Dosage and 
administration. Adults and children, 1 2 years and over: Two tablets up to four times daily as required. 
Max. 8 tablets in 24 hours. Children 6-12 years: Half to one tablet three or four times daily as required. 
Max. 4 tablets in 24 hours. Do not use for more than 3 days without doctors advice. Children under 
6 years Not recommended. Doses should not be repeated more frequently than every 4 hours, 
Contraindications: Known hypersensitivity to ingredients. Precautions: Renal or hepatic impairment, 
non-cirrhotic alcoholic liver disease. Contains parahydroxybenzoates - may cause allergic reactions. 
Interactions: Domperidone, metoclopramide, cholestyramine, warfarin or other coumarin anticoagulants. 

Pregnancy/lactation: Use in pregnancy should be on doctor's advice. Not contraindicated in breast feeding. 
Side effectsThrombocytopenia. agranulocytosis, anaphylaxis, hypersensitivity including skin rash, angiodema, 
Steven Johnson syndrome, toxic epidermal necrolysis, bronchospasm and hepatic dysfunction. 
Legal category: 1 6's Compack GSL, 32's R Product licence number: PL 0007 1 /044 1 . Product licence 
holder: GlaxoSmithKline Consumer Healthcare, Brentford, TW8 9GS, U.K. Package quantity and RSP 
(excl.VAT): 1 6's Compack £ 1 .23. 32's £2.37. Date of last revision: June 20 1 0. Panadol is a trade mark 
of the GlaxoSmithKline group of companies. 

MP3 player supplied will differ from one shown. 

Copyright 20 1 0, GlaxoSmithKline 
Consumer Healthcare. All rights reserved. 

Have your say on C+D's news. Email us at: 

Croup Editor 

Gary Paragpuri MRPharmS 
020 7921 8045 
News Editor 

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Jennifer Richardson 020 7921 8084 

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NiallHunt 020 7921 8185 

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Phil Johnson 020 7921 8106 


firstname. surname 


Three seemingly unrelated events - 
an award-winning pharmacy in 
Orkney, the pharmacy supervision 
rules, and the latest funding 
announcement for England's 
contractors - say a lot about the 
state of play of pharmacy practice. 

Let's start with the stunning 
Sutherland's Pharmacy, which won 
second place and £2,000 in C+D's 
Platinum Design Awards (p20). 
There are refits and then there are 
complete top-to-bottom overhauls 
that propel your business into the 
premier league - and in the case of 
Sutherland's, it's the latter. 

Fabulous, eye-catching design 
aside, it's the attention to detail in 
the way the pharmacy team works 
that stands out. For example, the 
use of tills that can also access the 
PMR system at the flick of a switch 
makes perfect sense. How many 
times do you speak to a patient at 
the counter and find that you need 
to disappear back into the 
dispensary to check the patient's 
medication or allergy history? 

Sutherland's Pharmacy's solution 
seems so obvious that you wonder 
why it isn't more widely used. 

Perhaps it's because the average 
pharmacy is dispensing around 
5,000 items per month and because 
pharmacists don't fancy a criminal 
conviction if they make an error The 
end result: rather than spend more 
time with patients, pharmacists are 
wedded to the final check and 
struggling to find a way that allows 
them to add real, measurable, and 
reimbursable patient benefits. 

So the current focus on 
supervision coming from the RPSCB 

and the PDA couldn't have come at 
a better time (p6) The existing rules 
that dictate what you can and can't 
do are over 40 years old and simply 
do not fit with what's expected from 
a modern pharmacy - either by the 
public or by pharmacists. 

The overarching rule that one 
pharmacist is in charge of one 
pharmacy must remain (Anything 
else - except in very exceptional 
circumstances - would see patient 
safety incidents go through the 
roof ) And within this, pharmacists 
must be given the freedom to 
delegate work to appropriate staff, 
so they can spend more time with 
patients adding the clinical value 
that they are trained for and that the 
NHS so desperately needs 

It sounds great and it's a point 
that has been made countless times 
before. Pharmacists can deliver more 
of the services that the NHS is crying 
out for, but they can't do it without 
sustained and fair funding. The 
ludicrous manner in which enhanced 
services come and then go according 
to PCTs' debt levels is an absurd way 
of incentivising pharmacy. It does 
little besides confirming what 
pharmacists already know about 
where PCTs' priorities lie. 

Against this background of where 
the sector needs to be, the news 
that £140 million is being clawed 
back by the Department of Health 
doesn't exactly inspire hope (p6). 

PSNC hopes to begin discussions 
on funding reform to reward quality 
and outcomes. It can't come soon 

Gary Paragpuri, Editor 

6 Contractors face £140m Cat M hit 

7 Calls for rosiglitazone to be withdrawn 

8 Fee flouting restoration bid fails 
10 Your guide to pharmacy PR pilots 
12 GSK launches free pain podcast 
14 Xrayserand David Reissner 

25 Classified 
30 Postscript 

15 Update: medicines adherence 

Convincing patients to take their medicine 

18 Practical approach 

What might be causing a teenager's flaking rash? 

20 Platinum Design Awards 

A winning redesign on remote Orkney 

23 Ten things about... neuropathic pain 

Key points in light of the revised Nice guidance 

® UBM Medica. Chemist+Druggist incorporating Retail Chemist. Pharmacy Update and Beauty Counter Published Saturdays by UBM Medica. Ludgate House, 245 Blackfnars Road. London SE1 9UY. C+D online at: Subscriptions: With C+D Monthly pricelist £250 (UK), without pncelist £205 (UK) ROW price £365. Circulation and subscription UBM Information Ltd. Tower House. Sovereign Park. Lathkill St. 
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Contractors facing category M 
hit of £140m under funding deal 

Prepare for clawbacks now, warns PSNC chief, as individual pharmacies face £1 3,000 cost 

Chris Chapman 

Contractors in England are facing a 
category M clawback of £140 million 
under the latest contract deal, with a 
£60m hit scheduled for October, 
PSNC has announced. 

The category M deductions will 
come in three waves: £60m taken in 
October, a further £60m in January 
and the remaining £20m over the 
course of the next financial year. 

Pharmacies were due to pay back 
all £140m in excess purchase profits 
in 2010-2011. But pharmacy 
minister Earl Howe has allowed 
£20m to be carried into 2011-2012 
to "smooth the impact", PSNC said. 
The clawback works out at around 
an extra £13,000 for each of the 
10,500 pharmacies in England. 

Overall funding for community 
pharmacy services in England for 
2010-11 has been agreed at 
£2.49 billion. This is an increase of 
around £170m on the £2.32bn sum 
agreed for 2009-10. 

PSNC chief executive Sue Sharpe 
warned contractors to prepare now 
for the financial loss. 

She said: "Contractors will no 
doubt feel the effects of excess 
margin recovery when January 

payments come through. We 
recognise the impact that category 
M adjustments will have in the 
second half of the year, and we urge 
contractors to prepare for this now." 

However, contractors were 
fortunate the clawbacks were spread 
out, and not combined into a shorter 
timeframe, Mrs Sharpe said. 

PSNC was expecting to discuss 
funding reforms with the 
Department of Health in the near 
future to reward quality and 

outcomes, Mrs Sharpe added. 

Mike Hewitson, of Beaminster 
Pharmacy in Dorset, said he was 
"gutted" about the size of the hit. 
"That's a member of staff. And why? 
Because we're buying better than 
[the government] thinks we can." 

Independent Pharmacy 
Federation chair Fin McCaul, called 
for an overhaul of the contract to 
alleviate the problems. "We're stuck 
in swings and roundabouts, so there 
is no confidence in the business and 

cash flow is difficult to manage... 
anyone who invested in the past 
three months has just seen their 
cashflow wiped out," he said. 

PSNC said the results of its cost of 
service inquiry would not be known 
for "several weeks". 

However, Earl Howe has agreed to 
reserve £250m, a proportion of 
which will be held as a risk share, in 
the event the inquiry shows 
underfunding for the sector, the 
negotiating body added. 

Remote supervision debate 
heats up at RPS conference 

Errors reprieve due in 
autumn health bill 

The government will put a clause in 
the health bill this autumn to 
decriminalise dispensing errors, 
the chief executive of the Royal 
Pharmaceutical Society has 

In her keynote address to the RPS 
Conference this week, Helen Cordon 
said: "We continued to push for 
dispensing errors to be decriminalised 
and the latest information we have 
is that the government will put a 
clause in their new health bill this 
autumn to do as we asked." 

However, it remains unclear how 
quickly any change to the law will 
arrive. The MHRA told C+D this July 
that any changes to the Medicines 
Act made before its 2012 review 

would require legislative change. 

But speaking to C+D in response 
to Ms Gordon's comments, the 
MHRA said: "While we do not think 
it will be realistic to achieve 
legislative change via the health bill 
the MHRA will consider any 
possibilities that could deliver the 
necessary change in advance of the 
bulk of changes arising from the 
review of the Medicines Act." 

A spokesperson added: 
"Discussions over the autumn will 
need to take account of the wider 
work of the review to ensure that the 
overall approach taken is coherent." 

Ms Gordon's comments came in 
her first public speech as Society 
chief executive. HF 

Remote supervision divided debate 
among attendees at a fringe session 
on supervision at the RPS 
Conference in London this week. 

Chaired by vice-chair of the 
English Pharmacy Board Sid Dajani, 
the debate centred on the eight 
principles for supervision released by 
the RPSGB last month. These include 
a declaration that all patients should 
have their medicines supply 
overseen by a pharmacist. 

Independent pharmacist Graham 
Phillips responded: "I am not willing 
to remove the pharmacist from the 
scene. As a clinician I am not willing 
to do that. 

"You can't say you can be out of 
the pharmacy for two hours as you 
don't know what's going to happen 
in those two hours." 

The debate comes ahead of an 
expected government bid to review 
existing supervision laws next year. 

Changes could see pharmacists 
able to run pharmacies without 
being physically present. 

This remote supervision concept 
has been heavily criticised by the 
industry, but attendees from Wales 
and Scotland argued the concept 
could ensure patients in remote 
parts of the UK had access to services. 

Director of pharmacy for NHS 
Highland John Cromarty said: 
"Remote access is a problem, the 
area I cover has an area of 12,500 
square miles. Many patients have no 
access to community pharmacy." 

Debate attendees also questioned 
how the RPS will engage members 
in the supervision consultation. HF 



Become an MUR master. Register for a C+D training course at 

Expert panel told MHRA 
to abandon rosiglitazone 

Drug remains available despite CHM safety warning two months ago 

Chris Chapman 

Drugs watchdog the MHRA was 
advised almost two months ago that 
rosiglitazone should be withdrawn 
as its dangers outweigh its benefits, 
it has emerged. 

The UK's Commission on Human 
Medicines (CHM) told the MHRA 
"the risks of rosiglitazone outweigh 
its benefits and it no longer has a 

Pharmacists can cut care home 
medication errors by 91 per cent if 
given full responsibility for 
medicines management, a trial 
scheme has found. 

The four-month trial, by 
Midhurst Pharmacy in London, 
introduced an intensive 
pharmacist-led pharmaceutical 
intervention programme at a 69- 
bed higher-dependence care home. 

gunmen jailed 

Two men have been jailed for 
robbing two Belfast pharmacies at 
gunpoint last year. 

Glen Henry Beattie, 21, pleaded 
guilty to two counts of robbery, one 
at a pharmacy on Ballygomartin 
Road, Belfast, on June 17, 2009 and 
one at Woodvale Pharmacy, Enfield 
Street, Belfast, on July 1, 2009. 

He was sentenced to eight years 
in prison at Belfast Crown Court. 

Andrew Peden, 24, pleaded not 
guilty to the robbery at Woodvale 
Pharmacy, and was found guilty of 
robbery and possession of a pistol 
and a crossbow. He received a 10- 
year jail sentence. 

Mr Beattie stole £192 from the 
pharmacy on Ballygomartin Road, 
and the two gunmen took £115 from 
Woodvale Pharmacy. 

Pharmacist John Dobson of 
Woodvale Pharmacy said: "They 
were both wearing ski masks, which 
added to how scary the robbery was 
as you can't read their facial 
expressions." HF 

place on the UK market" in July, 
an investigation by the BMJ under 
the Freedom of Information Act 

Rosiglitazone is still available in 
the UK, but the MHRA has passed its 
concerns to the European Medicines 
Agency (EMEA). 

The MHRA confirmed the CHM 
statement, adding it had advised 
healthcare professionals on 
cardiovascular restrictions and 

Internal medicines errors such as 
changes in dose, medication or out 
of date records were reduced from 
69 at baseline to only six during the 
trial period. 

The trial follows an alert from 
the Department of Health in 
January, warning that older people 
in care homes were exposed to a 
higher rate of medication errors 
than those in the community. EJ 

monitoring requirements of the drug 
on July 26. 

Rosiglitazone is currently under 
review by the EMEA after two papers 
sparked concerns over the drug's 
cardiovascular risk. 

An EMEA committee was due to 
conduct a risk-benefit review of 
rosiglitazone last Wednesday, with a 
final verdict on the drug's fate 
scheduled for September 23. 

Currently, the EMEA advises 
healthcare professionals "to strictly 
follow the current restrictions in the 
product information" when 
prescribing the drug. 

GlaxoSmithKline, which 
manufactures rosiglitazone under 
the brand Avandia, refuted the 
claims there was a lack of 
safety data on the drug, and 
urged patients who may have 
concerns to discuss treatment 
with their GP. 

"We continue to believe that 
Avandia is safe and effective when it 
is prescribed appropriately," the 
manufacturer added. 



Did you know some PCTs only 
spent 2p per patient on pharmacy 
enhanced services last year? We 
lift the lid on PCT commissioning 
at the C+D Senate Live on 
October 11 at Birmingham's NEC. 
Get your free ticket at 

Quiz the RPSGB boss 

C+D is offering two pharmacists 
an opportunity to interview 
Society chief Helen Gordon. To 
enter simply email your top five 
questions for the new RPSGB boss 

NCSO endorsements 

The following are allowed NCSO 
endorsements for September 
prescriptions in England and 
Wales: dexamfetamine 5mg 
tablets, gabapentin lOOmg and 
300mg capsules, and ofloxacin 
400mg tablets. 

iPod winner 

Congratulations to Darshan 
Negandhi of ABC Pharmacy who 
has won an iPod after completing 
C+D's Stock Survey. 

Scots board wants access 

The RPSGB Scottish Board will 
campaign for greater access to 
health records under its pharmacy 
manifesto 2011. Board chair 
Sandra Melville made the call in 
her RPS conference address. 

First CPD hearing 

The case against the first 
pharmacist to be referred to 
the RPSGB's Investigating 
Committee for breaching CPD 
standards was heard this week, 
as C+D went to press. 

The graduates 

The first MPharm graduates have 
qualified from Wolverhampton 
University. Thirty two students 
collected their honours last week. 

More on these stories online 

1 1.09.10 7 

Boots plans to roll out a raft of cancer support services under a three-year deal 
with a leading cancer charity. Boots marketing director Elizabeth Fagan (centre 
right) and Ciaran Davene, chief executive at Macmillan Cancer Support (centre 
left) celebrate the partnership that will see 15,000 Boots pharmacy staff trained 
by Macmillan. Early work will focus on the support and services that are available 
through Macmillan. Future targets include extensive cancer advice and support 
services. The partnership comes as a YouGov poll revealed that cancer is the 
biggest health worry for over half of the population. Boots staff will also raise 
funds for Macmillan, aiming to clock up 290,000 miles - one for every person 
diagnosed with cancer in the UK each year MC 

Pharmacist meds management can stop 
nine in 10 care home errors, trial reports 


Pharmacist investigated for CPD breaches 

Dispensary p harmadst who f loute<J 

Did you get a longer fees fails restoration bid 

break over the bank 

holiday or did you work? Applicant must wait further six months to re-apply, says committee 

"I took a 
longer break 
and went to 
Spain with the 
kids over the 
bank holiday, 
as they were 

Malvern Pharmacies Croup, 

"I usually 
don't work 
Mondays and 
only work four 
days a week. 
However, we 
have a shift 
rota for bank 
holidays and I 
had to work 

on the Monday last week. So I 
actually worked longer hours!" 
Rachna Chhatralia, Day Lewis, 
Wellington, Surrey 

Web verdict 

Yes, I took a longer break 54% 

No, I had to work 46% 

Armchair view: Nearly half of 
pharmacists are providing cover on 
bank holidays according to this 
week's C+D survey. Only 54 per cent 
of respondents reported taking a 
longer break over the August bank 
holiday weekend. 
Next week's question: 
As the RPSGB prepares to relaunch 
as a new-look leadership body, we 
ask, does the Society deserve a 
second chance? Vote at 

A pharmacist who continued to 
practice despite failing to pay his 
retention fee has failed in a bid to be 
restored to the register 

Damien Johnston, of Belfast, had 
committed a serious abuse, a 
Northern Ireland statutory 
committee hearing ruled. 

He had flouted a registration 
process that assured the public that 
those acting as pharmacists were 
properly accredited, the committee 
chairman Tim Ferris said. 

Mr Johnston worked as a 
pharmacist on seven occasions 
between September and December 

2009, despite being removed from 
the register for non-payment of fees. 

During the locum shifts he had 
dispensed, on one occasion, schedule 
2 controlled drugs, the committee 

Mr Johnston deliberately misled 
his employer about his unregistered 
status, the hearing was told. 

Authorities were alerted after a 
pharmacy annual return showed he 
had been employed as a locum. 

Mr Johnston fully accepted he had 
acted in a way that constituted 
misconduct at the hearing. 

He offered no defence other than 

that he had no money to pay the 
retention fee in June 2009. 

Mr Johnston was fully aware of 
the implications for him after his 
name was removed from the 
register, the committee was told 

The statutory committee 
acknowledged Mr Johnston's full 
acceptance of the facts and his 
otherwise unblemished record. 

Mr Ferris said his removal should 
not be forever and he could re-apply 
in six months. The verdict came as 
PSNI removed 18 pharmacists from 
the register this September for 
failing to pay fees. Contrib 

Clinical debate C+D's Chris Chapman looks at the evidence behind the headlines 

How to prove you're competent 

How can a patient be sure you 
know what you're talking about 
when it comes to medicines and 
health advice? You might say the 
answer is simple: you have an 
easily checkable registration 
number. But, actually, it doesn't 
mean a thing. 

In April, the previous 
government made tentative plans 
to ensure all practitioners of 
complementary therapy must 
be registered with the 
Complementary and Natural 

Healthcare Council. This includes 
anyone providing aromatherapy and 
reflexology, and will soon include 
acupuncture and general 'healing'. 

Former health minister Andy 
Burnham argued for the move, 
recognising that herbal remedies are 
unlicensed, but that the register 
would "increase public protection, 
but without the full trappings of 
professional recognition". 

Unsurprisingly, this suggestion 
caused a bit of a stir in science 
circles, with fans of evidence-based 
medicine warning that the scheme 
would be based on accreditation, not 
whether treatments actually work. 
And as charity Sense About Science, 
which this week demonstrated 
against the suggestion outside the 
Department of Health, points out, a 
member of the public won't know 
the difference between a recognised 
health professional and someone 
registered to provide a 
complementary therapy. 

There are added complications in 

the pharmacy world, too. Only 
pharmacists who decide to join 
the professional leadership body 
will have the post-nominal 
MRPharmS to show patients as 
added 'proof. But it's not a legal 
requirement to join the new 
Society, or a measure of 
professionalism or added 
competence. It's the GPhC 
registration that matters to 

By keeping a register, healthcare 
professions make a pact with 
the public. They say that this 
person - doctor, dentist, 
pharmacist or nurse - is at a set 
competency for providing 
evidence-based healthcare. 

A register of complementary 
therapists would only add 
confusion to an already mudded 
picture, and potentially be to the 
detriment of patients. 

Chat with Chris on Twitter: 


8 Chemist+Dru 

David Reissner: The inside track on stat comms 

C+D Keynote Conference at the Pharmacy Show 

October 10-11 The NEC Birmingham 
Register for your free ticket at 


"Piarrhoea Pialo 


W?> rtTtJ ttd iM* i fan ili lili iiHIter^ 1 1 liimiliiiii 

hoea is as difficult to talk about as it is to spell) 

new "Diarrhoea dialogue" initiative has been designed to support you through those awkward conversations, 
providing you with the tools to help offer your customers the advice they need. 

For more information call 01344 864 042 or visit 



Loperamide hydrochloride 
& Simeticone 


_ Watch the pharmacy tsar on the new pharmacy regulations 

Your guide to pharmacy PR pilots 

Pharmacy has always struggled to match higher profile GPs and nurses in the publicity stakes. 
The 2008 white paper promised a remedy with a PR campaign for the sector. Four PCTs have 
been given £1 52,000 to pilot the initiative. Hannah Flynn checks on their progress so far 

Dudley PCT 

The campaign: 
To get more 1 6 
to 24-year-olds 
into pharmacies 


How have they 
Planning social 
media campaign, 
attending social 

December 2010 

South West 
Essex PCT 

The campaign: 
The PCT aims to 
work with 
to reduce 
disease among 


How have they 
An integrated 
social marketing 

Late 2010 


"We have been doing some research into what barriers 
there are to people in the 16 to 24 age group in 
accessing pharmacy. We found people don't know 
what is offered at pharmacies and are unsure about 
the level of confidentiality. They wanted to know if 
speaking to a pharmacist was confidential, like 
speaking to a GP We are planning four one-day 
communication sessions with pharmacists and counter 
staff to ensure young people are communicated with 


"NHS South West Essex believes that community 
pharmacists can play an increasing role in improving 
access to health services as they are conveniently 
located within communities and often have extended 
opening hours, making it easier for workers to access 
this service. 

"After a successful pilot, involving 20 pharmacies 
in Basildon and Tilbury, NHS South West Essex is 
refining the service. The PCT worked closely with 
participating pharmacists to help them introduce the 
service, and by training counter staff. However, where 
pharmacists have underperformed, the testing kit 
will be reallocated to pharmacists in Grays, an area of 
high deprivation." 

Portsmouth PCT 

The campaign: 
A 'Healthy Living' 
campaign across 
all pharmacies 


How have they 
Advertising on 
buses, road show, 
website launch, 
radio advertising, 
in-store branding 

Launched August 

North Yorkshire 
and York PCT 

The campaign: 
The PCT plans 
to increase the 
number of 
45 to 55-year-old 
males accessing 
pharmacy advice 
and services 


How have they 
Local newspapers 
and community 
networks and 

November 2010 

"We wanted an 
campaign. We have 
our 'Healthy Living' 
pharmacies, but we 
want their work 
to have a halo 
effect on other 
pharmacies in the area. Areas of deprivation in our 
PCT had high numbers of people attending A&E who 
didn't need to be there, and the objective of this 
campaign is to make people aware of the health 
expertise pharmacy can deliver." 

"We provided a pharmacist and a technician to the 
campaign's road show, which I think helped increase 
general awareness. I think the campaign may, in an 
indirect way, benefit us. The full impact of the PR 
campaign is yet to be seen, but bringing a banner to 
the public about pharmacy must be a positive thing." 
Baldev Laly, owner of Lalys Pharmacy, Portsmouth 


"We hope this project will shed new light on the 
reasons why men in this age bracket don't use 
community pharmacies to their fullest potential. By 
taking a social marketing approach to this project, we 
hope to uncover men's perceptions towards community 
pharmacy, the barriers that prevent them using 
pharmacy and explore ways to remove these barriers. 

"Preliminary engagement with pharmacy staff in the 
Scarborough area has already revealed some 
interesting insight. One area we are planning to 
explore further is the role that partners play in 
influencing the health of men. We are also exploring 
aspects such as accessibility and the perception that 
pharmacy could be seen as a more female-friendly 
"The campaign will help as it offers a whole package to 
our customers, and encourages people from all 
avenues of life to come in. The 45 to 55 age group 
traditionally under-attends and this campaign will give 
us another group to work with. It is incredibly 
satisfying as a pharmacist to be able to engage in J 
health prevention with an individual before they come 
in with a health issue." 

Sandra Hutchinson, Boots Pharmacy, Scarborough 

The C+D Daily 

Get the latest news, views and comment straight to your inbox 
Sign up today at 

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10C ernist : Druggist 1 1 .09.1 


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For more information on the Canesten range please visit the Canesten website at C gyi24 j une 2010 


Rt ecu mill; 

Check what's on TV this week 

Should homeopathic 
remedies be labelled 

"I don't think 
we should 
label them 
as placebos 
as these 
products are 
marketed as 

amounts of 
medicines, so if we label them as 
placebos that is misleading." 
Bhavesh Patel, Pharma 
Healthcare, Canvey Island, Essex 


placebos may 
misuse, as 
they do 
some of 
them are 
suspended in alcohol. You don't 
want people to think of medicines as 
completely benign." 
Ajith Adai, Chernistree Pharmacy, 
St Albans, Hertfordshire 

Web verdict 



Armchair view: The pharmacy 

community is split over the 

suggestion by the BMA that 

pharmacists should label 

homeopathic remedies 'placebos', 

according to our poll. 

Next week's question: 

Are there too many cough and cold 

remedies to choose from? Vote at 


GSK launches free pain podcast 

GSK Healthcare has launched a 
podcast to assist pharmacists and 
pharmacy assistants in pain 

The free 10-minute podcast will 
be delivered by the Panadol brand 
and offers interviews and case 
studies for pharmacy teams to use 
as training to improve their pain 

The 10 Minute Pain Podcast is 
delivered in a disposable MP3 player, 
says GSK Healthcare. 

The free podcasts will be available 
upon request through trade 
advertising, direct-mailed reply paid 
cards, on GSK's pharmacy 
community website - - or by 
calling 0800 783 3927. 

Market focus 

• £21 1m- total adult 
analgesics value. 

• 3 per cent - increase in the 
total adult oral analgesics 
market in 2009. 

Source: Kantar WorldPanel value sales 
52 weeks to November 29, 2009 

GSK Healthcare 
Tel: 0800 783 3927 

ICaps website supplemented with new advice 

Alcon has updated the 
website of its eye 
supplement product ICaps. 

The consumer website 
has been designed to offer 
advice to customers on eye 
health and nutrition, 
according to an ICaps 

It now has an 'Ask The 
Expert' function, offering 
advice from a research 

Makeover for mypharmassist 

GSK Healthcare has relaunched its 
online pharmacy community 
Acting on feedback from the 



pharmacy sector, the company said 
it has created a more user-friendly 
site, including a simplified 
registration process, faster log in and 
quicker access to all areas 
including training. 

CPD and other pharmacy 
staff training are available in 
a variety of formats - 
including e-zines, interactive 
e-learning modules and 

It is also possible to 
download free display 
material from the website. 

GSK Healthcare 

Tel: 0845 762 6637 

The website also contains 
product and stockist 
information, according to the 

It can be accessed at: 

The move follows the 
introduction of a one-a-day 
formula earlier this year. 


Tel: 0800 092 4567 

Kalms in one-a- 
night product 

LanesHealth is launching Kalms 
Night One-a-Night, a herbal product} 
for the relief of sleep disturbances. 

The launch will be supported by 
television advertising for the range, a 
PR campaign and POS to support 
the launch including pens, shelf 
strips, signature mats, post-it notes 
and leaflets, says the company. 

Kalms Night is a one-a-night 
formulation containing dry extract 
of the herb valerian. 

Price: £4.99/21 
Pip code: 356-6148 
LanesHealth; tel: 01452 507458 




Check your mail for your 
GPhC information pack! 

12 11.09.10 

Winter needn't 
be woeful 

Fluoride Mouthrinse 
- The Evidence 

Our oral health as a nation has 
improved considerably over 
the last three decades. Today, 
in most instances, dental 
diseases are preventable by 
adopting appropriate daily 
oral care regimes and regular 
visits to the dentist. 

In a review paper on how 
best to prevent a number 
of oral diseases including 
dental caries (tooth decay), 
the strength and extent of 
evidence supports advising 

I FluoriGari • FluoriGard I 


Alw.iv> ip.hI Ihp label 

patients to use appropriate fluoride mouthrinses to help prevent dental 
caries. It states that: 

• Mouthrinses containing 0.05% sodium fluoride (225ppm fluoride) for 
daily use have been shown to reduce tooth decay significantly in the 
permanent teeth of children over 6 years and adolescents. 

• Fluoride mouthrinses, in addition to daily use of fluoride toothpaste, are 
also beneficial to adults and the elderly. 

• Ideally mouthrinses should be used at a different time of day to twice 
daily toothbrushing with fluoride toothpaste to maximise the benefit of 
additional fluoride. 

The Department of Health publication: 'Delivering Better Oral Health - 
An Evidence-based toolkit for prevention' 2 includes guidance to dental 
professionals on prescribing a daily fluoride rinse containing 
0.05% fluoride (225ppm F) as a way of increasing fluoride availability to 
prevent caries. 

Colgate FluoriGard fluoride mouthrinses contain 0.05% fluoride (225ppm). 
Colgate FluoriGard Daily rinse is clinically proven to reduce caries.' Colgate 
FluoriGard Alcohol Free rinse offers fluoride protection in a formulation that 
does not contain alcohol, making it ideal for patients who may prefer to 
choose an alcohol free option. 

For further information, please call the Colgate Customer 
Care team on 01483 401 901 or visit 

Colgate FluoriGard Daily rinse 

Legal Status: GSL, PL 0049/0012 

References: 1. R M Davies The Prevention of Dental Caries and 
Periodontal Disease from the Cradle to the Grave What is the 
Best Available Evidence? Dental Update, May 2003 1 70- 1 70 
2. Delivering Better Oral Health-an evidenced based toolkit for 
prevention, September 2009 3. Marinho et al, (2002), 
Cochrane Database Syst Rev no 3 


Ajit Malhi, head of 
marketing services for 
AAH Pharmaceuticals 

Winter is approaching and 
I imagine that you are all in 
the throes of preparing for 
a change of ailment to treat 
as the long, dark nights 

On that note we're delighted 
here at All About Health that 

so many of you have prepared well for the winter and signed 
up to deliver our award-winning flu vaccination service. 

This is excellent news, but I can't stress strongly enough 
the importance of marketing the service to push this out to 
your communities with added gusto. Recent figures released 
by Novartis Vaccines, our partner in delivering the flu 
vaccination service, demonstrate that 90 per cent of patients 
receiving the flu vaccination in a pharmacy would return for 
further vaccinations if they were made available. 

However, the good work that you all do to promote 
the service has been highlighted superbly by the 37 per 
cent who said that they only had the flu jab because the 
pharmacy was promoting it. 

Evidence indeed that good marketing works well and this 
is an ideal time to sing about the service and its convenience 
to customers both loyal and new. 

Accompanying the impending flu season will be the fourth 
issue of our All About Health magazine. Judging by the 
requests that we get to fulfil additional orders with you, this is 
clearly going down a treat with your customers. 

This issue brings more celebrity health secrets from 
Ben Fogle and former spice girl turned TV hostess Emma 
Bunton. It also features a winter colds special to coincide 
with new point of sale materials landing with you. 

These are exciting times for pharmacy and this is the 
first time I have sat down to write this article since the 
changes in Government and since Andrew Lansley set about 
restructuring the NHS. 

There are sniffles and sneezes awaiting us on the horizon 
and some questions to be answered in the corridors of 
power, but let's tackle them head on and make the most of 
how we can guide our customers this winter and beyond. 

For more information: 


AAH customers should contact their 
AAH Business Manager to get involved 

All About 



What do you think? 

Assessing the threat to your business 


They say stressed is when you wake up screaming, 
then realise you weren't actually asleep. An image 
we may all be familiar with, but I've become 
concerned recently not about stress insomnia, but 
that pharmacy is sleepwalking into a nightmare. 

Our PCT has started to widely publicise its 
pharmaceutical needs assessment (PNA), the 
document that will shape not only what services 
need be commissioned from pharmacies, but also 
where. In many quarters this was hailed as a relief 
from the uncertainty of the current "necessary or 
expedient" lottery, as it is supposed to make for 
granting of contracts based on assessed need. This 
was supposed to mean that a neutral body - the 
primary care trust - would assess where patients 
needed services, and so the geographical spread 
would be dependent on population requirements 
rather than where was most profitable. 

All well and good, you may think. But then our 
current chimera government decided to do away 
with PCTs, and replace them with CP 
commissioning groups. Suddenly the whole 
premise changes again as interpretation of the 
PNA becomes all, and I'd bet that the 
interpretation in many cases will be that the 
greatest need for pharmacy services could be 
within any number of CP practices. "Oh no," I hear 
you cry, "of course that won't happen..." 

Since owning Xrayser pharmacy, I have been 
threatened twice. The first was the ubiquitous 
addict with used needle and syringe, but the 

second was more sinister. The lead CP from our 
local surgery came in, and expressed the partners' 
anger that I had appealed the decision for a 
contract in their surgery. "This is costing us time 
and money," he fumed. As my heart bled for them, 
I explained how this move could reduce my 
business by a third and that, unlike them, I did not 
have an NHS pension. I also explained that we had 
not done it lightly or spitefully. We shook hands, 
and he left with better understanding, but as he 
turned to go his parting words were: "We will have 
a pharmacy, whatever happens." 

And that threat is present in the PNA for all of 
us, yet so few seem aware of the power of this 
seemingly innocuous document - the conclusions 
of which are not open to appeal. Despite 
numerous articles in C+D, my fear is that - 
distracted by the countdown to the CPhC and yet 
more new guidelines - contractors may be looking 
the wrong way, and not see that someone new is 
going to assess the value of their service provision 
and thus the value of their business. So when your 
PCT asks for contribution make sure you respond, 
because if you think you're the only interested 
party - well, dream on! 

What's happening with the PNA 
in your area? 

How do the new GPhC standards measure up? 

At first sight, the CPhC standards are 
rather like motherhood and apple 
pie: hard to find anything to disagree 
with. Even though they largely 
replicate the RPSCB's standards, a 
fresh reading and some small 
changes, mean there are some eye- 
catching items. 

For example, pharmacists and 
pharmacy technicians must keep 
full and accurate records of the 
professional services they provide. I 
realise that dispensing is invariably 
recorded in the PMR (although I 
sometimes see problems because 
the date of dispensing is not 
necessarily the date of supply to a 
patient). There is a reason to 
document services when payment 
depends on having a record. But do 
all pharmacists record the advice 
they give, or when unwanted 
medicines are received for disposal? 

I foresee some requirements will 
cause tension in the workplace, 
however high-minded the principle. 
For example, pharmacists have an 

obligation to make sure their 
professional judgement is not 
affected by organisational interests 
or targets; and they will have a duty 
to challenge the judgement of 
colleagues and other professionals if 
there are reasons to believe their 
decisions could affect the safety or 
care of others. 

I also hope there will be guidance 
to explain what the standards mean 
when they say that, in addition to 
cases where they have consent or 
are required by law, they may only 
disclose confidential information in 
"exceptional circumstances". 

RPSCB standards required 
pharmacists in positions of authority 

- including responsible pharmacists 

- to ensure there is a retrievable 
record of the pharmacist taking 
responsibility for the provision of 
each pharmacy service. This has 
caused difficulties when an error is 
made and no one can identify which 
pharmacist was responsible 

The Society was never able to 

spell out a foolproof method of 
record-keeping The nearest it got 
was to encourage the use of 
'dispensed by' and 'checked by' 
boxes on dispensing labels, but the 
system only works if individuals 
initial the boxes in an identifiable 
way - and if the dispensing container 
has not been discarded. The CPhC 
repeats the obligation but places it 
on the shoulders of pharmacist 
owners and superintendents. 

I wonder if the CPhC recognises 
the practical difficulties in 
maintaining a retrievable record of 
which pharmacist checked every 
single prescription. Superintendents 
can put systems in place, but it 
should be up to the responsible 
pharmacist to implement them. 
David Reissner is a specialist in 
pharmacy law and head of 
healthcare at Charles Russell LLP 
pharmacy). Contact him on 0207 
203 5065 or email david.reissner@ 


14 Chemist 11.09.10 





15 Medicines adherence ^ 18 Seborrhoeic dermatitis r 20 Sutherland's Pharmacy ▼ 23 Neuropathic pain 

Your weekly CPD revision guide 

Medicines adherence 

How pharmacists can convince patients they need to take their medicine 

Parastou Donyai PhD, MRPharmS 



u read this article? 

This CPD article will help you develop 
skills to improve medicines adherence by 
working with patients. It will cover the 
ons for non-adherence, and coaching 
ues to improve concordance. 

hu are patients 

Factors that affect adherence include 
social and economic factors, lack of 
knowledge from healthcare team members, 
condition-related factors, therapy-related 
factors and patient-related factors. These 
factors are complex so no single 
intervention is suitable for all patients. 
Tackling deliberate non-adherence could 
involve discussing patient beliefs, while 
forgetful patients may benefit from 
reminder technology. 

at techniques can I use? 

g techniques can improve 
cordance. These include weighing pros 
id cons and encouraging patients to 
step into the role of others affected by 
ir treatment. 

et Update emailed to you each week, 
ister for C+D's CPD newsletter at 

Supported by 


At the beginning of 2010, the all-party pharmacy 
group met to discuss pharmacists' roles in 
improving medication adherence. Three areas for 
improvement were highlighted: 

education and training - to increase 
pharmacists' confidence when discussing 
medicines with patients 

® practical tools to help pharmacists monitor and 
regulate adherence 

• universally commissioned initiatives to help 

It was also suggested pharmacists should spend 
more time talking to patients newly prescribed 
medicines for long-term conditions. Encouraging 
adherence means more than just giving 
information; it involves telling patients a story 
about their treatment that convinces them there is 
a need for it. 

Adherence is the extent to which patient 
behaviour matches the recommendations of a 
healthcare provider. A distinction is often made 
between intentional and unintentional non- 
adherence. 12 With intentional non-adherence, 
the patient has decided not to follow the 
recommendations, whereas with unintentional 
non-adherence the patient either forgets and/or is 
not paying attention. Sometimes both elements 
may be at play. 

Adherence factors 

Non-adherence to medicines is a problem 
worldwide. The World Health Organization 
(WHO) published a comprehensive report on 
medicines adherence in 2003 that outlined why 
patients fail to take their medicines and provided 
some possible solutions. 3 

Adherence is affected by the interaction of five 
key dimensions: 

" social and economic factors - eg poverty, 
illiteracy, access to healthcare and medicines, 
effective social support networks, cultural beliefs 
about illness and treatment 

healthcare team and system-related factors - 
eg lack of knowledge, lack of tools, poor 

5 condition-related factors - eg depression has a 
considerable effect on adherence 

• therapy-related factors - eg the dose frequency 
and the incidence of side effects 

» patient-related factors - eg lack of information 
and skills, difficulty with motivation and self- 
efficacy, and lack of support for behavioural 

As these factors are complex, no single 
intervention or package of interventions is 

effective for all patients, conditions and settings 
Comprehensive interventions, combining 
cognitive, behavioural, and emotional 
components, are thought to be more effective 
than single-focus interventions. Realistically, a 
community pharmacist is unlikely to have much 
control over social and economic or condition- 
related factors However, there are some ways in 
which the pharmacist's own behaviour, therapy- 
related and patient-related factors could be 
tackled to improve adherence. 

According to the WHO, adopting certain 
communication styles with patients is proven to 
work. Tactics include: 

• making sure your patients are satisfied with the 
service you generally provide 

talking positively 

■ providing information 

■ asking patients specific questions about 

i following patients up, building a partnership 

■ being warm and empathetic and providing 
emotional support. 

Behavioural science also offers useful theories, 
models and strategies for impacting on patient 
behaviour. Research focused on changing patients' 
attitudes and behaviour has shown the following 
can work: 

• promoting self-care and enhancing patient 

e increasing concern about the consequences of 
the disease without treatment 

• enhancing the perceived value or confidence of 

• providing clear patient instructions - start early, 
ideally when a new treatment is prescribed. 

For therapy-related factors, pharmacists should: 

• educate the patient about their medications and 
the conditions for which they are prescribed 

i review the patient's medication history 

• continuously monitor the patient's therapy 

• screen for potential adverse effects 

« monitor the patient's ability to take their 
medications correctly and to adhere to the 
prescribed therapies. 

In 2008, researchers in Denmark published a 
generic adherence programme to help improve 
patients' chronic medication use. Taking the WHO 
recommendations, they produced an 
individualised, multi-dimensional adherence 
counselling programme. 4 

The process of the intervention was summarised 
in the following short formula: "Find the patient, 
get the story, check for errors, find the resources 
together with the patient, share goals, agree 




V 15 Medicines adherence ^ 18 Seborrhoeic dermatitis ^ 20 Sutherland's Pharmacy ▼ 23 Neuropathic pain 

on plan, get it done and follow up". 

The model begins by allowing patients to talk 
about their medication use. The idea is that letting 
patients tell their story helps pharmacists identify 
key issues and then helps the patient create a more 
suitable version of the story, with the right 
resources and solutions. In this next stage of the 
model the pharmacist uses 'coaching' techniques, 
in effect asking a series of questions to help the 
patient realise the answers for themselves. 
Patients can choose from among the solutions 
they have come up with during the session, based 
on what they feel capable of implementing in their 
own lives. Thus the coaching process is ultimately a 
means of creating a concordant partnership 
between the patient and the pharmacist. See table 
1, below, for the model's coaching questions. 

According to the researchers, intentionally non- 
adherent patients have typically made their 
decisions based on several subjective feelings and 
experiences (eg misunderstandings, negative 
feelings, lack of support, lack of confidence in the 
healthcare system and personnel, lack of 
confidence in medications, low self-esteem, bad 
experiences). With unintentional non-adherence, 
forgetfulness is often the problem and the patient 
may only need help for the execution of the 
treatment - hence packaging and reminder 
technologies may be helpful. Therefore very 
different approaches are needed to improve 
adherence depending on the patient's type of 

Helping patients with adherence is not a 
straightforward task. Although a plethora of 

studies exists, the inconclusive nature of the 
evidence means there is no definitive best practice 
advice. Complex interventions that take account of 
individual patient situations combined with 
enhanced delivery/communication skills might 
work in some cases, where story telling and 
discovering patient resources could lead to an 
agreed action plan and further follow-up. 
References are online in the full version of this 
article at 

Parastou Donyai is a lecturer in pharmacy 
practice at the University of Reading 

Download a CPD log sheet that helps you 
complete your CPD entry when you 
successfully complete the 5 Minute Test for 
this Update article online (p17). 

Table 1 : Suggested 
coaching questions 4 

Reactions from others 

If your doctor were here now, what would 
he think about your condition and your 

Would he be satisfied? 

What would he think should be done? 

If we asked your family/network, what 
would they say? 

Are they worried about your condition? 
© Do they have wishes or suggestions that 
you often hear? 

Weighing pros and cons 

How do the 'errors' you make today 
benefit you? 

What are the disadvantages? 

On a scale from 0-10, how do you rate the 
importance of, for example, improving your 
peak expiratory flow rate? 

In the best of all worlds... 

What will the drug treatment of your, eg 
asthma, be like in five years? In six months? 

What would be the most important change 
needed to make things go that well? 

What would be the smallest change needed 
to make things move forward? 

Noticing success 

Who would notice if you were taking a drug 
therapy that you were happy about? How? 

What would they see you doing? 

Seeing possible goals 

Based on our talk, what would you suggest 
we do to get the best possible outcome? 

Assessing options; what would happen if... 

We had your doctor change your medicine? 

We sent you an SMS every day? 

You had your medicine dispensed in a dose 
administration aid? 

I gave you more information about your 
illness and your medicine? 

You came here to the pharmacy to have 
your, eg asthma, monitored? 

Case study: non-adherence in 
an older patient with asthma 

Alma is a grandmother in her late 60s. She is a 
highly proactive person who volunteers for a 
charity and looks after her two grandchildren. 
She is referred to the pharmacist by her GP for 
her deteriorating asthma and suspected non- 
adherence. She is prescribed a salbutamol and a 
beclomethasone inhaler. 

Alma seems motivated, knows the 
importance of taking her medication and 
considers herself adherent, but forgets to use 
her steroid inhaler when her routine is 
interrupted by her grandchildren's schedule. 

The pharmacist believes Alma's patient 
medication record indicates under-use. Alma 
says she uses her inhaler as planned but says 
"of course slips and lapses happen when your 
attention is elsewhere, but is there really much 
harm in missing a few doses?" Alma believes 
that these lapses could not really make a 
difference, but also knows that her wheezing has 
continued and that her peak expiratory flow rate 
has deteriorated, which she found worrying. 

The pharmacist conducts an MUR with Alma 
and talks about how she can remember to take 
her medicines when she is busy, explaining the 
consequences of missed doses. Alma says she 
often forgets to use her inhaler when she is 
called to stay over at her daughter's house to 
look after the grandchildren. Although she is not 
interested in anything too complicated, she is 
willing to listen and agree to something she 
might be able to try. The pharmacist and Alma 
agree to try two beclomethasone inhalers, so 
that Alma can have one to carry in her bag. The 
pharmacist also suggests that Alma is given a 
peak flow meter to monitor her own peak 
expiratory flow rate for recording on a chart. 


At first sight Alma appears to have no 
motivational problems or lack of knowledge 
about medicines. However, she does have a 
misunderstanding about the impact of missed 
doses 'now and again'. 

Once Alma understood the importance of not 
missing doses, she faced a behavioural problem, 
namely the need to have access to her 
medication when she was away. Alma would 
have been asked coaching questions by the 
pharmacist to pick up on her own version of the 
story, as well as questions that made her step 
into the role of others - what would her 
daughter want her to do and what would her 
grandchildren want to see? 

The coaching questions would have also 
identified Alma's willingness to take control of 
monitoring her peak expiratory flow rate. So in 
summary, rather than a simplistic model, the 
patient has been listened to in order to find the 
right tools for her individual case. 

Things to consider 

If Alma represents a patient you might not 
necessarily hold in high regard, would you think 
about your own mannerism when dealing with 
her? Remember, warmth and empathy can go a 
long way. 

Would you consider making plans for Alma 
to return so that you can continue the 

How about screening for potential adverse 
effects? Would you provide her with some 
advice about how to avoid them? 

Would you ask Alma to demonstrate her 
inhaler technique to make sure she does in fact 
have the ability to take her beclomethasone 


The first of a two-part series 

looks at the management of 

multiple sclerosis 

16 Chemist -Druggis I 1 1 .09.1 

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Medicines adherence 


What are the main factors affecting medicines 
adherence? What techniques can pharmacists use to 
impact on patient behaviour 7 

This article discusses medicines adherence and the role 
pharmacists can have in its improvement. It describes 
the factors affecting adherence and techniques for 
communicating with patients. There are coaching 
questions pharmacists could ask as well as a case study. 

• Find out more information about medicines 
adherence, involving patients in decisions about 
prescribed medicines and supporting adherence by 
reading the Nice quick reference guide at 

• Revise your knowledge of medicines adherence on 
the National Prescribing Centre website at, which includes 
information, quizzes and case studies. 

Think about how you can use the information in this 
article during MURs and when counselling patients 
starting new medication. How could you identify non- 
adherent patients in your pharmacy? 

Are you now confident in your knowledge of medicines 
adherence? Could you use your skills to find out why a 
patient was non-compliant and help them improve their 

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wake feeling 


IN, total sleeping aids, value sales, MAT to w/e 12 06 .10 

Hops, Valerian, Passion Flower 

Jytol and Nytol One-A-Night are aids for the relief of temporary sleep disturbance. Nytol Herbal Tablets an ; Legal categories: Nyl 

lytol One-A-Night P Further information is available from: GlaxoSmithKlme Consumer Healthcare, Brentfon : PA - 
lytol, Nytol One-A-Night 

Good Mornings Follow a Good Nytol are registered trade marks of the 

For consumer information, please visit 


Practical Approach 

What is my son's 
spreading rash? 

A woman comes into the Update 
Pharmacy trailing a reluctant 
young teenage boy behind her. She 
asks to speak to the pharmacist, 
David Spencer. 

"I wanted to take Kevin to the 
doctor," the woman says when 
David comes out to see her. "He 
refused to go but I managed to 
persuade him to come here." 

"What's the problem, Kevin?" 
David asks, turning to the boy. 

"Nothing much, just dandruff," 
Kevin replies. 

"It's more than that," his mother 
interjects. "It's quite nasty, flaking 
And it's spreading down his face - 
look." She points to red scaly 
patches around the boy's eyebrows 
and bridge of his nose. 

David asks: "Does it hurt or itch, 
Kevin? And why won't you go to 
the doctor?" 

"It itches a bit sometimes. But 
it's nothing much, it'll probably just 
go away soon. It's not worth 
hanging around in the doctor's," 
Kevin replies. 

The mother interrupts again: 
"Mr Spencer, do you know what it 
is, and do you have anything to get 
rid of it?" 

"Well, Mrs Evans," David replies, 
"I think I know what it is and there 
are several things available without 
a prescription that could clear it up. 
But Kevin, I have to warn you that if 
they don't work or it gets any 
worse, you will have to go to the 


1. What is Kevin likely to be 
suffering and what is the cause? 

2. What treatments are 
available without prescription. 

and how effective are they 
considered to be? 

3. What prescription treatments 
are used for this condition? 

4. What other therapies are 

1. Seborrhoeic dermatitis. The cause 
is unknown, but it is thought to be 
an inflammatory reaction to a yeast, 
Malassezia furfur. This may be a 
normal skin commensal, but 
patients with the condition may 
have reduced resistance to it. 

2. Ketoconazole 2 per cent shampoo. 
Several studies have validated its 
efficacy for dandruff and seborrhoeic 
dermatitis of the scalp. 

' Pyrithione zinc. Available mainly 
as 'medicated' shampoos that are 
not licensed as medicines. It has 
produced inferior results to 

e Selenium sulphide shampoo. It 
is as effective as ketoconazole, but 
less well tolerated and less pleasant 
to use. 

Coal tar. This has been shown to 
be significantly more effective than 
placebo. It is available as shampoos 
and an ointment (which also 
contains salicylic acid). 

Salicylic acid. It has a keratolytic 
effect, but in shampoos it may be 
too dilute and have insufficient 
contact time to be effective. 

3. Topical: hydrocortisone and other 
steroids (hydrocortisone cream is 
available without prescription, alone 
and in combination with miconazole, 
which has been found effective for 
seborrhoeic dermatitis, but licensing 
conditions prohibit use on the face); 
metronidazole gel, tacrolimus 

• Systemic: oral antifungals - 
terbinafine, fluconazole, 
itraconazole, ketoconazole. 

4. Phototherapy: UV light. Patients 
often experience improvement 
during the summer, and treatment 
with UVB has proven successful. 
Psoralen plus UVA (PUVA) is also 

References are at www.chemist 

For more Practical Approach 
scenarios, go to www.chemist 



tacrolimus prolonged release 

Presentations: Advagraf Prolonged -release hard capsules containing 
tacrolimus 5 mg, 1 mg, 3mg and 5 mg Program hard capsules 
containing tacrolimus 0.5 mg, 1 mg and 5 mg Indications: Advagraf 
and Prograf: Prophylaxis ot transplant rejection in adult liver or kidney 
allograft recipients and treatment ot allograft rejection resistant to 
treatment wrth other immunosuppressive medicinal products Posology 
and Administration: Advagraf and Prograf therapy require careful 
monitoring by adequately qualified and equipped personnel Either drug 
should only be prescribed, and changes in immunosuppressive therapy 
initiated, by physicians experienced in immunosuppressive therapy and 
the management ot transplant patients Dosage recommendations 
given below should be used as a guideline Advagraf or Prograf are 
routinely administered in conjunction with other immunosuppressive 
agents in the initial post-operative period The dose may vary depending 
on the immunosuppressive regimen chosen Dosing should be based on 
clinical assessments of rejection and tolerability aided by blood level 
monitoring. To suppress graft rejection immunosuppression must be 
maintained so no limit to the duration ol oral therapy can be given The 
daily dose of Advagraf capsules should be taken once daily in the 
morning with water at least 1 hour before or 2-3 hours after a meal. 
Prograf capsules should be taken as for Advagraf in two divided doses 
Advagraf In stable patients converted from Prograf (twice daily) to 
Advagraf (once daily) on a 11 (mgmg) total daily dose basis the 
systemic exposure to tacrolimus for Advagraf was approximately 10% 
lower than for Prograf The relationship between tacrolimus trough 
levels (Cw) and systemic exposure (AUC„ : ,) tor Advagrat is similar to 
thai of Prograt. When converting from Prograf capsules to Advagrat 
trough levels should be measured before and within two weeks after 
conversion In de novo kidney and liver transplant patients AUC,,., of 
tacrolimus for Advagraf on Day 1 was 30% and 50% lower respectively, 
when compared with that for Prograf at equivalent doses. By Day 4, 
systemic exposure as measured by trough levels is similar for both 
kidney and liver transplant patients with both formulations Race: In 
comparison to Caucasians, Afro-Caribbean patients may require higher 
tacrolimus doses to achieve similar trough levels Prophylaxis of 
transplant [election - liver and kidney Initial dose of Advagraf and 
Prograf capsules is 10-0 20 mg/kg/day for liver transplantation and 
20-0 30 mg/kg/day for kidney transplantation starting approximately 
12-18 hours for Advagraf and 1 2hrs tor Prograf after completion of liver 
or within 24 hours of completion of kidney transplant surgery. Dose 
adjustment post -transplant Advagraf and Prograt doses are usually 
reduced in the post-transplant period It is possible in some cases to 
withdraw concomitant immunosuppressive therapy leading to Advagraf 
monotherapy or Prograf dual therapy or monotherapy Post -transplant 
improvement in the condition of the patient may alter the 
pharmacokinetics ot tacrolimus and may necessitate further dose 
adjustments Dose recommendations - Conversion to Advagraf, Patients 
maintained on twice daily Prograf requiring conversion to once daily 
Advagraf should be converted on a 1:1 (mg:mg) total daily dose basis. 
Following conversion, tacrolimus trough levels should be monitored and 
if necessary dose adiustments made Care should be taken when 
converting patients trom ciclosponn-based to tacrohmus-based therapy. 
Initiate Advagraf after considering ciclosponn blood concentrations and 
clinical condition of patient Delay dosing in presence of elevated 
ciclosponn blood levels Monitor ciclosponn blood levels following 
conversion Dose recomm endations- Rejection therapy For conversion 
of kidney and liver recipients from other immunosuppressants to once 
daily Advagraf, begin with the respective initial dose recommended for 
rejection prophylaxis. In adult heart transplant recipients converted to 
Advagraf, an initial oral dose of 1 5 mg/kg/day should be administered 
once daily in the morning For other allografts, see SPC. Dose 
adjustments in specific populations: See SPC T arget whole blood trough 
concentration recommendations: Blood trough levels lor Advagraf 
should be drawn approximately 24 hours post-dosing, just prior to the 
next dose, for Prograf approximately 12 hours post-dosing Frequent 
trough level monitoring in the first two weeks post-transplant is 
recommended, with periodic monitoring during maintenance therapy. 
Monitoring is also recommended following conversion from Prograf to 
Advagraf, dose adjustment, changes in the immunosuppressive 
regimen, or co-admimstration ot substances which may alter tacrolimus 
whole blood concentrations (see 'Warnings and Precautions' and 
'Interactions'), Adjustments to the Advagraf and Prograf dose regimen 
may take several days before steady stale is achieved. Most patients 
can be managed successfully if tacrolimus blood concentrations are 
maintained below 20 ng/mL In clinical practice, whole blood trough 
levels have been 5-20 ng/mL in liver transplant recipients and 
10-20 ng/mL in kidney transplant recipients early post-transplant, and 
5-15 ng/mL during maintenance therapy Contraindications: 
Hypersensitivity to tacrolimus or other macrolides or any excipient. 
Warnings and Precautions: Medication errors, including inadvertent, 
unintentional or unsupervised substitution of immediate or prolonged- 
release tacrolimus lormulations, have been observed. This has led to 
serious adverse events, including graft rejection, or other side effects 
which could be a consequence of either under- or over-exposure to 
tacrolimus Patients should be maintained on a single formulation ot 
tacrolimus with the corresponding daily dosing regimen; alterations in 
formulation or regimen should only take place under the close 
supervision of a transplant specialist Advagrat only limited experience 
in non-Caucasian patients and those at elevated immunological risk. 
Advagraf is not recommended for use in children below 18 years due to 
limited data on safety and efficacy Advagraf and Prograf: During initial 
period routinely monitor blood pressure, ECG, neurological and visual 
status, fasting blood glucose, electrolytes (particularly potassium), liver 
and renal function tests, haematology parameters, coagulation values, 
and plasma protein determinations, consider adjusting the 
immunosuppressive regimen if clinically relevant changes are seen 
Herbal preparations, including those containing St John's Wort, should 
be avoided Extra monitoring of tacrolimus concentrations is 
recommended during episodes of diarrhoea. Avoid concomitant 
administration of ciclosponn Ventricular hypertrophy or hypertrophy of 
the septum (reported as cardiomyopathy) have been seen rarely, other 

' NHS Blood and Transplant, August 2009. NHS Transplant 
Activity in the UK, 2008-2009. 
t www June 2010. 

Job code PRG10028UK Date of preparation June 2010 

risk factors for these conditions include pre-existing heart disease, 
corticosteroid usage, hypertension, renal or hepatic dysfunction, 
infections, fluid overioad, and oedema. Patients are at increased nsk of 
all opportunistic infections including BK Virus associated nephropathy 
and JC Virus associated progressive multifocal leukoencephalopathy 
Physicians should consider this in their differential diagnosis in 
immunosuppressed patients with deteriorating renal function or 
neurological symptoms Patients have been reported to develop 
posterior reversible encephalopathy syndrome (PRES). It so radiological 
tests should be performed. If PRES is diagnosed, adequate blood 
pressure and seizure control and immediate discontinuation of 
tacrolimus is advised Echocardiography or ECG monitoring pre-and 
post -transplant is advised in high-risk patients, and dose reduction of 
and or a change of immunosuppressive agent should be considered if 
abnormalities develop Tacrolimus may prolong the OT interval Exercise 
caution in patients with diagnosed or suspected Congenital Long QT 
Syndrome EBV-associaled lymphoprohterative disorders have been 
reported Concomitant use ot other immunosuppressives such as 
antilymphocytic antibodies increases the risk of EBV-associated 
lymphoprolrferative disorders. EBV-VCA negative patients have been 
reported to have increased risk ot lymphDproliferabve disorders. EBV- 
VCA serology should be ascertained before starting tacrolimus 
treatment During treatment, careful monitoring with EBV-PCR is 
recommended Exposure to sunlight and UV light should be limited. The 
risk of secondary cancer is unknown Dose reduction may be necessary 
in patients with severe liver impairment The printing ink used to mark 
Advagraf capsules contains soya lecithin. In patients who are 
hypersensitive to peanut or soya, the nsk and seventy of hypersensitivity 
should be weighted against the benefit of using Advagraf capsules 
contain lactose Interactions: See SPC Pregnancy and lactation: 
Tacrolimus can be considered in pregnant women when there is no 
safer alternative See SPC Undesirable effects: Medication errors have 
been observed A number ot associated cases of transplant rejection 
have been reported (frequency cannot be estimated from the available 
data) Many of the following adverse drug reactions are reversible and/ 
or respond to dose reduction. Very Common (>1/10): Hyperglycaemic 
conditions, diabetes mellitus, hyperkalemia, insomnia, tremor, 
headache, hypertension, diarrhoea, nausea, renal impairment, 
infections, liver function test abnormal, Common (>1/10Q to <1/10): 
haematological abnormalities, hypomagnesaemia, hypophosphataemia, 
hypokalemia, hypocalcaemia, hyponatremia, fluid overload, 
hyperuncaemia, appetite decreased, anorexia, metabolic acidoses, 
hyperlipidaemia, hypercholesterolemia, hypertngiycendaemia, anxiety 
symptoms, mental disorders, confusion and disorientation, depression, 
mood disorders and disturbances, nightmare, hallucination, seizures, 
disturbances in consciousness, paresthesias and dysaesthesias, 
peripheral neuropathies, dizziness, wnhng impaired, vision blurred, 
photophobia, eye disorders, tinnitus, ischaemic coronary artery 
disorders, tachycardia, haemorrhage, thromboembolic and ischaemic 
events, vascular hypotensive disorders, peripheral vascular disorders, 
dyspnoea, parenchymal lung disorders, pleural effusion, pharyngitis, 
cough, nasal congestion and inflammations, gastrointestinal 
inflammatory conditions, gastrointestinal ulceration and perforation, 
gastrointestinal haemorrhages, stomatitis, ascites, vomiting, 
gastrointestinal and abdominal pains, constipation, flatulence, bloating 
and distension, loose stools, bile duct disorders, hepatic enzymes and 
function abnormalities, cholestasis and jaundice, hepatocellular damage 
and hepatitis, cholangitis, pruntus, fash, alopecias, acne, sweating 
increased, arthralgia, muscle cramps, limb and back pain, renal failure, 
oliguria, renal tubular necrosis, nephropathy toxic, bladder and urethral 
symptoms, asthenic conditions, febrile disorders, oedema, blood 
alkaline phosphatase increased, weight increased, body temperature 
perception disturbed, pnmary graft dysfunction Uncommon (>1/1000 
to < 1/1 00). coagulopathies, coagulation and bleeding analyses 
abnormal, pancytopenia, hypoproteinaemia, hyperphosphataemia, 
hypoglycaemia, coma, central nervous system haemorrhages and 
cerebrovascular accidents, paralysis and paresis, encephalopathy, 
speech and language disorders, amnesia, cataract, arrhythmias, cardiac 
arrest, heart failures, cardiomyopathies, infarction, deep venous 
thrombosis, shock, respiratory failures, respiratory tract disorders, 
asthma, paralytic ileus, peritonitis, acute and chronic pancreatitis, 
anuria, haemolytic uraemic syndrome, uterine bleeding, psychotic 
disorder, multi-organ failure. Rare l>1/10.000 to<1/1000): thrombotic 
thrombocytopenic purpura, blindness, neurosensory deafness, 
pericardial effusion, acute respiratory distress syndrome, subileus, 
pancreatic pseudocyst, hepatic artery thrombosis, venoocclusive liver 
disease, toxic epidermal necrolysis (Lyell's syndrome). Very rare 
(<1/10.00Q including isolated reports!: hepatic failure, Stevens Johnson 
syndrome, nephropathy, cystitis haemorrhagic, Neoplasms. Con sult ff|e 
SPC for complete information on side effects and full prescribing 
information. Package Quantities, Basic NHS cost & Product licence 
numbers: Advagraf/Prograf: 0.5 mg capsules x 50 = £35.79 
(EU/1/07/387/002)/£61.88 (PL 00166/0206). respectively. 1 mg 
capsules X 50 = £71.59 (EU/1/07/387/004)/£80.28 (PL 00166/0203), 
respectively. 1 mg capsules x 100 = £143 17 (EU/1/07/387/006)/£160.54 
(PL 00166/0203), respectively. 5 mg capsules x 50 = £266.92 
(EU/1/07/387/008)/£296.58 (PL 00166/0204), respectively. Advagraf 
3 mg capsules x 50 = £214 76 (EU/1/07/387/01 2). Legal Classification: 
POM Date ol Revision: May 2010. Further information available from 
Astellas Pharma Ltd, Lovert House, Lovett Road, Staines TW18 3AZ. 
Advagraf and Prograf are registered trade marks. For medical 
Information phone 0800 783 5018 

Adverse events should be reported. 
Reporting forms and information can be found at 
Adverse events should also be reported to 
Astellas Pharma Ltd - 0800 783 5018 


Leading Lighi for Life 

18 Chemist+Druggist 11.09.10 

I was one of 1190 people waiting for a kidney* 

5 years waiting 

12 hours of dialysis a week' 

180 hospital visits 

1 car crash 3 families affected 

2 ambulances 3 doctors 4 nurses 
1 specialist transplant team 

nrnnnmnJI l life-changing gift 

1 personalised drug regimeo 

Now it's up to you 

Tacrolimus. Be specific. 
Always use the brand name 




tacrolimus prolonged release 


Leading Light for Life 

Prescribing information can be found on the adjacent page 

JOb code PBG10O28UK date of oreparabon June 2010 


15 Med icines adherence ^ 18 Seborrhoeic dermatitis 20 Sutherland's Pharmacy ; 23 Neuropathic pain 


i ■ . 


Contractor Torquil Clyde 
focused on incorporating 
customer service into the 
award-winning design of 
his pharmacy on Orkney. 
Hannah Flynn reports 

Design factfile 
The pharmacy 

Sutherland's Pharmacy, Kirkwall, Orkney 

The contractor 

Torquil Clyde 

The challenge 

Completing a redesign in a remote, island 

Relocation including car access, electric doors, 
better integration of retail and dispensary 
space, more efficient dispensing and easy 
integration of new Scottish contract services 

£428,000, including robot 

Second place, C+D Platinum Design Awards 
2010, and a cheque for £2,000 


With its two entrances and roomy 
shop floor, the first thing that hits 
you at Sutherland's Pharmacy in 
Kirkwall, Orkney, is the space - unexpected to an 
outsider on such a small island. 

A redesign of the remote pharmacy, which 
took second place at this year's C+D Platinum 
Design Awards in association with Ceuta 
Healthcare, took place after it moved premises 
along the same road. 

Pharmacist Torquil Clyde's Sutherland's 
Pharmacy business is a mainly offshore one (it has 
several other branches, including in mainland 
Scotland), and the prospect of completing a 
redesign at such a remote location does not 
appear to have phased him. "The only difference 
was the cost of importing the supplies," he says. 

The prize-winning shop was designed by 
Anderson Retail Consultants, after Mr Clyde saw 
the work they had done for a previous Platinum 
Design Awards winner. According to Mr Clyde, 
they manufactured the entire shop interior off- 

site and then transported it to Orkney to be fitted 
over a seven-day period. 

'Drive-through' pharmacy 

One of the main challenges experienced at the 
previous Kirkwall site was the narrowness of the 
streets. The historic lane the pharmacy is on offers 
little space for cars or delivery vans to park. 
Customers had highlighted this issue in a survey 
the pharmacy carried out before deciding to move 
the shop. 

Mr Clyde says: "One of our objectives was to 
have another entrance that people could drive to 
but also one delivery drivers could use. So that is a 
big advantage of the site. 

"We were very keen to have electric doors as 
there is a lot of evidence there is better customer 
flow with electric doors and it helps people 
with prams, wheelchairs and buggies, and things 
like that." 

The rear car park contains a buzzer that 
disabled customers can use to alert staff when 




n Orkney 

The visually stunning Sutherland's Pharmacy 
in Kirkwall, Orkney, was designed with the 
new Scottish contract in mind and combines 
the tills and the PMR in one system to simplify 
access to patient information. Contractor 
Torquil Clyde is pictured far left, with his 
Platinum Design Award 

they arrive. They can also speak to staff in the 
dispensary via the system. 

"We did this for disabled access, and to show 
we were thinking about all of our customers," Mr 
Clyde says. 

"I guess you could call it a 'drive-through' 
pharmacy as they can press the button and we 
can come and serve them." 

He adds it is also used by parents with ill 
children who don't want to leave them in the car 
while they get prescriptions, so staff will also 
leliver medicines to them in the car park. 

European-style dispensing 

In the shop itself he had further plans to radically 
overhaul the way the staff did business. One 
objective was to integrate pharmacy and retail 
staff and make the whole dispensary more 
customer-facing. Mr Clyde also wanted to make 
the dispensing process more efficient. 

The introduction of the dispensing robot has 
allowed staff to focus on serving customers as 

quickly as possible and more are now on the shop 
floor, he says. 

"It is more like the European style and saves a 
lot of staff time so you don't have two staff out 
the back doing prescriptions and then staff out 
front doing the serving 

"When someone comes in with an acute script 
we literally scan it, the robot finds it instantly and 
by the time you have done the label the [product] 
is there and you can serve somebody in under one 
minute. It is almost too quick! Sometimes you 
want people to go away and shop. It is extremely 
quick for walk-in scripts." 

He also feels the customers benefit from the 
greater amount of interaction with the staff they 
now have because of the introduction of the 
dispensing robot. 

He says: "It is more direct. We are speaking 
directly to the customers and this feels better and 
more natural doing that. There is no 'please tell 
Mrs Jones to take her tablets at night'. No, you just 
tell her yourself, so that is a definite advantage." 

Design for the future 

Aware the chronic medication service (CMS) was 
soon to be introduced in Scotland, Mr ► ► 

Watch our interview with contractor Torquil Clyde 
and hear more about how his award-winning 
design was planned and executed on Orkney 

From the moment your pharmacy is connected to our enhanced, intuitive PMR system with its future-proof design, you 

are connected to a better future. So, with the demands being made on you by the current National Programmes, get better 
connected today. Call your ProScript LINK Account Manager, email or visit 







15 Medicines adherence 


18 Seborrhoeic dermatitis 20 Sutherland's Pharmacy 23 Neuropathic pain 

Sutherland's staff say: 

The robot has made it possible to serve some customers in less than a minute, says Torquil Clyde 

CPD Reflect • Plan • Act • Evaluate 

Clyde was keen the design would facilitate easy "Having our computers, which are Positive 

incorporation of services. The pharmacy has Solution computers, we find having the tills and 

several large consultation rooms but has also the PMR as one system means you can swap 

incorporated plans into the pharmacy's high-tech easily between one or the other and see a 
computer systems, which can switch between the customer's complete information, 
tills and PMR depending on who is using them "We also use loyalty cards quite a lot and if 

Mr Clyde says: "Thinking about Scotland in someone buys a P medicine on their loyalty card 

particular, with CMS coming, it is going to be so then it automatically goes onto their PMR record 
much easier for us than some pharmacists as we for review." 

are dealing directly with our customers. Customers have responded well to the changes, 

he adds. Many have reported how much easier it 

is to find products and are pleased the shop is so 

close to the old site and near the health centre 
Tips for your CPD entry on pharmacy design Qne regular customeri E[eanor McBeathi says 

REFLECT Does my pharmacy present a she en J°y s the customer service the pharmacy 

professional image and support offers and feels offers a lot of extra services that 

work processes? other Pharmacies don't. 

She says: "It is easier to find things now, before 

PLAN Consider how a refit or smaller jt was wry cramped , haye defjnite[y seep fl [qX 

layout changes could improve more customers since the redesign. It is a lot 
image and work processes busier in here now." 

ACT Implement refit or layout changes Mr Clyde is pleased with the results of the 

EVALUATE Have public image and workflow desi § n and said he ho P es t0 roU out the chan § es 

he has made to his other shops, including another 
improved? v ° 

offshore site on Shetland. 

Accountant Richard Baker explains the tax issues to 
bear in mind when considering fit-outs and refits 

When undertaking a fit-out or refit project, one 
thing that often gets missed is the tax aspect. 
You may think that spending money on this 
legitimate business expense will automatically 
qualify for tax relief. Generally that is the case, 
but it is the timing of the tax relief that can vary 

Expenditure on these projects falls into a 
number of categories. It may: 

• qualify for capital allowances (which is the 
taxman's version of depreciation) 

• qualify as an expense, mainly where refits are 
concerned, which is tax deductible in the year of 
the spend 

qualify for tax relief when the asset (often the 
related property) is eventually sold 

• never qualify for any tax relief (for example, 
improvements to a leasehold property which do 
not qualify for capital allowances or as a tax- 
deductible expense). 

Expenditure that qualifies for capital 
allowances is categorised into 'plant and 
machinery' and 'integral features'. 

This expenditure is then written down at 

20 per cent and 10 per cent per annum 
respectively for tax purposes. 

In 2008, the government introduced an 
Annual Investment Allowance. From April 1 this 
year, the first £100,000 of capital expenditure in 
any year (as long as it qualifies for capital 
allowances) will qualify for immediate tax relief. 
If you are spending more than this, it can be 
allocated to integral features first to accelerate 
the tax relief. 

A further point to consider is expenditure on 
'energy-saving equipment'. This qualifies for 
immediate tax relief. Energy-saving equipment 
could include air conditioning systems, 
refrigeration equipment and lighting. A full list is 
available of qualifying products. 

Finally, you can help your accountant to save 
you tax by gathering as much information as 
possible on the cost of the refit or fit-out, so that 
the expenditure can be correctly classified. 
Richard Baker is a partner at accountancy 
firm Horwath Clark Whitehill and C+D's 
Finance Zone columnist 

Next month: Platinum Design Awards 2010 
first prize and Best Multiple Pharmacy 
winner Murrays Healthcare, Malvern 

• PLUS Your guide to legal considerations 
for fit-outs and refits 

22 Chemist+Dru ist 11.09.10 





4 15 Medicines adherence 4 18 Seborrhoeic dermatitis 4 20 Sutherland's Pharmacy V 23 Neuropathic pain 


Neuropathic pain 

Following the publication of Nice guidelines on the pharmacological management 
of neuropathic pain, Gavin Atkin explains what you need to know 

Neuropathic pain arises from damaged or dysfunctional nerves, and 
can be due to a range of disorders affecting the peripheral and central 
nervous systems, including diabetic neuropathy, post-herpetic 
neuralgia and trigeminal neuralgia. 

People with neuropathic pain may experience altered pain sensation, 
areas of numbness or burning, and continuous or intermittent evoked 
or spontaneous pain. Neuropathic pain is an unpleasant sensory and 
emotional experience that can have a significant impact on a person's 
quality of life. 

Neuropathic pain remains difficult to treat because it is resistant to 
many medications and the effective treatments have adverse effects. 

Patients should be referred to a specialist pain clinic or disease-specific 
specialist at any stage if their pain is severe or limits daily activities, or 
their underlying health deteriorates 

Patients' concerns and expectations should be addressed when 
agreeing which treatments to use, and these are likely to include the 
benefits and possible adverse effects of pharmacological treatment, 
coping strategies for dealing with pain and the adverse effects of 
drugs, and non-pharmacological treatments including surgery and 
psychological therapies. 

The selection of treatments should take comorbidities, safety issues 
and contraindications into account, as well as mental health problems. 
The titration process must be explained, and when withdrawing or 
switching treatment, doses should be tapered. Clinicians should 
consider overlapping treatments to maintain the pain control. 

Patients should be reviewed shortly after a change in treatment to 
ensure it is suitable, and should be reviewed regularly. 

In patients where the source of pain is not associated with diabetes, 
the first-line treatments are oral amitriptyline starting at lOmg/day 
gradually titrated upward to the maximum tolerated dose up to 
75mg/day, or pregabalin starting at 150mg/day (or less in some 
patients) in two daily doses with upward titration to the patient's 
maximum tolerated dose of no higher than 600mg/day. If satisfactory 
pain reduction is not achieved with first-line treatment at the maximum 
tolerated dose, the patient should be referred to a pain clinic or offered 
another drug in addition or as an alternative to their first-line treatment. 
The third-line options are oral tramadol and topical lidocaine. 

In patients whose pain is due to diabetic neuropathy, oral duloxetine 
should be offered as a first-line treatment, starting at 60mg/day (less 
in some patients). Where duloxetine is contraindicated, amitryptyline 
should be offered. 

If amitryptyline proves effective but the patient is unable to tolerate its 
adverse effects, oral imipramine or nortriptyline should be considered. 

Reference: Neuropathic pain - pharmacological management, 

CPD Reflect • Plan • Act • Evaluate 

Tips for your CPD entry on neuropathic pain management 

REFLECT Do I understand current guidance on the pharmacological 

management of neuropathic pain? 

Assess which aspects of neuropathic pain management you 
are least clear about 

Read this article and the relevant secti ons of the Nice 
guidance (see reference above) 

EVALUATE Can I advise GPs and patients on drug treatment for 
neuropathic pain? 


1 1.09.10 51 23 

Sunday, October 10 


Monday, October 1 1 



^ See below 

for details . 


The five biggest challenges facing pharmacy and what the Society 
will do to help you 

Helen Gordon, chief executive, the RPS 

As the RPSCB returns to its roots as the leadership body for 
pharmacists, its new chief executive reveals how the Society will steer 
pharmacists to a more rewarding professional future 

How your life will change under the new pharmacy regulator 
Duncan Rudkin, chief executive, General Pharmaceutical Council 

Pharmacists have a new professional regulator but will it just lead to 
tougher sanctions or will the promise of 'light touch' regulation become 
a reality? The CPhC's Duncan Rudkin reveals what the profession's new 
disciplinarian will mean for you 


The inside track on stat comms and what pharmacists have to do to 
ensure they get a fair hearing 

David Reissner, head of healthcare, Charles Russell solicitors 

With community pharmacy now facing more scrutiny than ever 
before, David Reissner looks at the common reasons pharmacists get 
prosecuted and offers tips on what you should do if an inspector calls 

Pharmacy contract funding - a behind-the-scenes account of where 
we are and what the future holds 
Sue Sharpe, chief executive, PSNC 

PSNC chief executive Sue Sharpe explains what's happening in the 
latest round of contract funding negotiations and what the future NHS 
Commissioning Body will mean for your funding 





with "actavis 

The C+D Senate Live in association 
with Actavis 

C + D's pharmacy think-tank holds its 
first ever live event. An expert panel 
will discuss the big issues impacting 
on grassroots pharmacy practice and 
will field questions from the audience. 

Don't miss this unique chance to be 
part of the debate. 
Panellists include: Ian Facer, Rob 
Darracott, Sue Sharpe, Michael Cann 
and David Reissner 

Every session will include an audience Q+A 
PLUS interactive voting technology 


The new white paper - where next for NHS services? 
Alan Milburn, former secretary of state for health. 

The government's vision for primary care will see GPs charged with 
commissioning local services as PCTs are consigned to the scrap heap. 
Alan Milburn examines whether the new NHS blueprint will change the 
NHS landscape for better or for worse 


A multiple's view of the new look NHS 

Andy Murdock, director of pharmacy, Lloydspharmacy 

Following the white paper theme, Lloydspharmacy's Andy Murdock 
identifies the opportunities and threats that pharmacy faces under the 
latest NHS revolution 

What the new dawn in pharmaceutical wholesaling means at the 
coal face 

Mark James, managing director, AAH 

Quotas, DTP, discounts and parallel trading - the supply chain is the 
one topic that affects every pharmacist. Mark James cuts through the 
crossfire and looks for a workable solution 


Generics, the NHS, and you 
Michael Cann, chairman, BGMA 

Love 'em or hate 'em, generics play a major part in keeping the NHS 
drugs bill down. Michael Cann looks at the opportunities that generics 
provide for pharmacists including category M and generic substitution 

How ditching toiletries and cosmetics helped boost our healthcare 

Kenny Black, managing director, Rowlands Pharmacy 

Rowlands Pharmacy has piloted a new front of shop business model 
which has seen toiletries and cosmetics replaced with a greater focus 
on healthcare. Kenny Black explains why pharmacy must change and 
shares top tips from the Rowlands experience 


How to press your PCT's buttons when it comes to local 

Julie Wood, director, clinical commissioning, NHS Alliance 

There's no escaping the 'c' word - it's a fact that commissioning is going 
to be a big part of pharmacy's future. Julie Wood offers her tips on what 
you need to do to get services commissioned 


An examination of Co-op's blueprint for pharmacy 

Chris Brooker, business development director. The Co-op Pharmacy 

The Co-operative Pharmacy is one of the fastest growing multiple 
chains. Chris Brooker shares the company's blueprint for pharmacy and 
offers his tips on maximising your business 



Hundreds more jobs online 

0207 921 8123 

Booking and copy date 
12 noon Monday prior 
to Saturday publication 
subject to availability 

Contact: Andrew Walker 
Tel: 0207 921 8123 
Fax: 0207 921 8132 

Ludgate House 
245 Blackfriars Road 
London SE1 9UY 

■ University of 



Technician Grade 5, Pharmacy Practice 

Ref 1156723/CD 

Salary £21,578 £24.287 Base Colerame 

Closing date 24 September 2010 

The postholder will be lequired to support the day-to-day operations 
related to pharmacy practice within the Department of Pharmacy and 
Phaimaceutical Sciences 

We prefer to issue and receive applications via our on-line recruitment 
website at jobs 

Hard copy applications can be obtained by telephoning 028 701 2 3456 

The University is an equal opportunities employer and welcomes applicants from all 
sections of the community, particularly from those with disabilities Appointment will be 

made on merit 


Package negotiable London (South) 

An established and leading niche pharmaceutical and 
healthcare products company is looking for an experienced 
professional to head up a new marketing department and take 
responsibility for sales and a small sales team. 

The successful candidate will, in addition to possessing skills in 
consumer marketing, be an innovator in his or her approach 
to new product launches, design and consumer and trade 
advertising and promotion. Although not absolutely essential, 
you have probably worked in the industry and have a good 
knowledge of retail pharmacy and pharmaceutical wholesaling. 

As this is a new position we are looking for an individual who 
understands the inextricable relationship between sales and 
marketing and has excellent communication skills to develop 
the role both internally and externally. 

In return, the Company is offering a comprehensive package 
with the great potential to grow with this exciting business. 

Please send full details/CV to: 
P. O. Box No: 8 1 23, Chemist and Druggist, 
Ludgate House, 245 Blackfriars Road, London SEI 9UY 

"I find it really rewarding to 
be developing pharmacists 
of the future." 

"There's always been a strong commitment 
to development here. That's why, as well as 
getting to know my new customers, I've also 
been passing on my own experience and 
knowledge to our Preregistration Trainee 
and Pharmacy Undergraduate Summer 
Placement Student." 

Find out more from Jina and about 
becoming a Pharmacist or Pharmacist 
Store Manager by visiting 

feel good 



Enthusiastic Pharmacist required to manage and provide the 
full range of services in our established and well supported 
branch in Abingdon. 
Excellent Salary 
Send your CV by email: 
or coll on 01 582 560393 No agencies please. 

Eynsham, Grove Wantage & 

Currently recruiting 
Relief & Pharmacy 

{negotiable + excellent benefits 

Please call Maria McElvenney on 
02476 432983 and email your CV to 

Lloydspharmacy (^) 

Healthcare lor life 


Relief & Pharmacy 
Managers required 

{negotiable + excellent 

Please call Maria McElvenney on 
02476 432983 and email your CV co 
maria.mcelvenney " 


Hea'thcare for life 



Register for your free ticket at 

Meet the C+D Jobs team at the 2010 Pharmacy Show (^^j 

North Devon 

Relief Pharmacy 
Managers required 

Negotiable, flexible contracts 
+ excellent benefits 

Please call Maria McElvenney on 
02476 432983 and email your CV to 

Lloydspharmacy (@) 

Healthcare for life 

Princes Risborough, Buckinghamshire 

Pharmacist & 
Pharmacy Manager 

For our established community 
branch & new 'Premium' store 

{negotiable + excellent benefits 

Please call Maria McElvenney on 
02476 432983 and email your CV to 

Lloydspharmacy Qj^) 

Healthcare for life 

Take the first step into your new career 

J J /) for information on our vacancies contact Katnona on 
020 8256 6222 or e-mail 

day lewis 


HANDBOOK 2009/10 

Your pocket guide to Locum Pharmacy Practice 





Pharmacy Manager - Shropshire Border 

Pharmacy manager or long term locum 
required for village pharmacy. 

* Short working week of ONLY 32 hours, but can be flexible. 

* No week-ends. Half day Wednesday. 

* No MUR's. No pointless paper-work. 

* Excellent salary package offered to right candidate. 

* Five weeks per year or more by negotiation. 

Contact Adrian Edwards on 01624 837893 
or e-mail adrian edwards(a) 

Dispensing Assistant/Technician 
Required - Part or Full Time 

Working towards or qualified to 
NVQ level 2 or 3. the ideal 
candidate will have the right 

experience to carry out a 
supervisory role in our new 
pharmacy located at The Flitwick 
Surgery. Flitwick, Bedfordshire. 

The closing date tor this application 
is Friday 10th September 

For an application form 
please email 

Bishopsworth & Whitchurch, 

Pharmacists required 

Negotiable + excellent 

Please call Maria McElvenney on 
02476 432983 and email your CV to 

Lloydspharmacy @) 

Healthcare for life 






Foundation Degree (FdSc) in Pharm 
Practice, Science and Management 

This degree, devised specifically for practicing pharmacy 
technician professionals, is offered by The School of Pharmacy, 
Birkbeck and Westminster-Kingsway College. These three 
institutions are leaders in London for pharmacy, lifelong learning 
and technician training and for this degree are in partnership 
with NHS practitioners and managers. Attendance is one 
afternoon and the same evening a week during term time. 

The foundation degree provides good Continuing Professional 
Development (CPD). It allows technicians to develop skills and 
confidence in pharmacy practice in primary and secondary care 
and the managed care sector. 

Find out more at our Open Evening from 5.45pm-7.15pm 
on Monday 18th October 2010 in Rooms B62/B64 
Main Building, Malet Street, London WC1E 7HX 
(entrance via Torrington Square). 

For further information: 




The School of Pharmacy 

University of London 



J l * - 1 ■ i . I *t ■ y 

26 Chemist+Druggist 1 1.09.10 

Call 0207 921 8123 

0207 921 8123 

Contact: Andrew Walker 


Business Sales 

0121 362 8880 ENGLAND & WALES or 
01324 631542 SCOTLAND 


Drowning under paperwork, 
SOPs and information governance? 

st a 


orried about the potential increase in capital gains tax? 

Why not sell? 

Quick sale guaranteed! 
Cash available! 

For further information please contact 
Colin Caunce on 07966 524162 



Come and meet Hutchings Consultants at 

on 10/11TH OCTOBER 2010 
at the NEC Birmingham 

We are pleased to announce that as the 
NPA's only approved agent for pharmacy sales, 

purchases and valuations throughout the UK, 
we will be exhibiting on the NPA Stand No. B50 
at the pharmacy show. 

We will be delighted to meet you to discuss the services 
we offer and to advise how we can assist you 
in the successful sale of your pharmacy. 

For information about our services please visit our website 

Or for a free valuation please call 

01494 722224 


Hutchings Consultants Ltd 

"We are the only NPA 
approved supplier for 
selling your pharmacy " 


I National Pharmao 
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valuing and selling 
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Think Pharmacy Finance: Think Pharmacy Partners 


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0808 \UU 5554 I infofa 

the legal prescription 

Cost effective specialist legal advice 
to independent retail and community 

We can assist with buying, selling, merging 
and demerging pharmacy businesses as 
well as related leases, sales and purchases 
of commercial premises 





Hilary D'Cruz or Jas Singh 
01543 466 660 



Shop fitters? Advertise here every Saturday 
Call 0207 921 8123 


J Pharmacy Development Group 

Trading group terms aggregated discount up to 
the equivalent of 13.23% from zero threshold 

Pre Registration Training Programme Support 


Your pharmacy website home page to promote 
your services 

Full support on Pharma< y Contract allowing 
members to implement new opportunities 


Call Freephone 0800 526074 & ask for Customer Services 
quoting reference No. CDSEPT 
Or Fax on 01530 814914 Or Email 

Are you Overstocked? 

Knights will help you sell your excess 

Check out our website - what can you 
offer us? 


Pharmacy design and shopfitting 
without compromise 



t: 0845 450 5904 



NJL YORKLINE • 0800 070 0102 


Call 0207 921 8123 


As the leading tax consultants to retail pharmacists we 
have clients throughout the UK. 

We know many pharmacists are happy with their accountants 
but are not getting proactive tax advice. 

We have the answer. You don't need to change accountants 
- we can work alongside them solving your tax problems 
and advising you how to reduce your tax bills. 

Some clients like a total service provider - others like 
to keep their existing accountant and just use our tax 
consultancy services. 

"We are happy to work in the way 
that suits you" 

Call us NOW to discuss how we can help you? 
Phone Anne Hutchings on: 01494 722 224 


Hutchings & C <>. 

The Leading Tax Consultants 
for Retail Pharmacists. 

Maple House, 
53-55 Woodside Road, 
Amersham, Bucks 
HP6 6AA 


At last, the practice mortgage that gives you the freedom of 
the entire wholesale market - no more quotas, less loan 
capital to pay, giving you total freedom to operate your 
practice without restriction. 




Contact George Knox on 
0191 2584645 / 07963 375383 



Chemist+Druggist remains the clear leader 

in influencing stock decisions* 
*Linda Jones Associates Industry Survey 2009 





Ddiplus provides the following 
compliance services at a FIXED price: 

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Quarterly management accounts 

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Ad hoc telephone and email advice 


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GP margin 

Turnover compared to other similar clients 

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Net profit margin 

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Other tax planning areas 

Long term financial planning 

For more information or for a 
FREE consultation please call Urmesh 

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Got a story for Postscript? 

New pharmacy role is inflated 

A pharmacist in Redbridge has gone beyond the 
call of duty to get the safe sex message out for his 
PCT's campaign. 

Jason Muir, manager of Daniels Pharmacy in 
east London, has donned a full body inflatable 
condom suit and will be handing out free condoms 
to 16 to 25-year-olds outside the shop this month. 

Sponsored by Pasante, which provided the 
costume, and funded by Redbridge PCT, the stunt 
is designed to encourage young people to come 
into the pharmacy to take advantage of free 
condom and lube packs, free chlamydia screening 
and other sexual health services. 

It has been timed to coincide with Redbridge 
PCT's sexual health campaign. 

Mr Muir says: "It is not practical to stand there 
in a condom suit getting people to fill out forms, 
which they need to do to get hold of the free 
condoms normally. So we are giving them flyers 
with information about sexual health services in 
the pharmacy, which have a condom stuck to 
them. People are really responding well." 

Daniels Pharmacy has the suit for two more 
weeks, when it will be replaced by a hi-tech 
glow-in-the-dark condom costume from the 

"The PCT has asked me to go clubbing in the 
glow-in-the-dark suit," Mr Muir adds. "It's pretty 
hot in that thing. It's sweaty and grim, but it does 
appear to be having the desired effect." 

Jason Muir: suited, booted, pumped up and ready to meet his 
Redbridge pharmacy customers 

A social tweet 

From luminous condoms to toxic megacolon, 
join the debate at 

@Squeelaa: I never thought I would hear the 
words "Toxic Mega Colon" but I just have. It's 
almost made my day. 

2. Oxford pharmacist faces death threats 

@CandDHannah: I have just spoken to a 
pharmacist whose PCT has asked him to go 
clubbing in a glow-in-the-dark condom. Respect. 

@GaryParagpuri: On my way to BBC's Portland 
Place for R4 debate on supply chain problems. 
Spoke to a pharmacist last night and we struggled 
to find a solution. 

@CandDChris: Toxic Megacolon is a serious 
complication. But yes, it does sounds like a 
particularly villainous giant stompy robot. 

@VicThompson: Neuropsychopharmacology 
looks like a typo. 

3. Stock shortages soar as supply chain hits crisis 
@CandDChris: @VicThompson the real problem is I point, C+D survey finds 

when you get into neuropsychopharmacokinetics. 

4. Co-operative Pharmacy profits soar 26 per cent 

@CaryParagpuri: Just been asked to submit my 

CPD to the RPSGB. No idea what they'll make of 5. Manufacturer supply deals blamed for drug 
my entries or how patients benefit from me. shortages 

@The Web Hunter 

As I write, this column is somewhere around two 
days late, but unlike with vital medicines, the only 
likely outcome is that I will get earache from 
C+D's production editor. 

As our exclusive 2010 Stock Survey reveals, 
there are some serious issues in the UK medicines 
supply chain. And as the story gains traction in the 
wider media, it is interesting to see what aspects 
of our findings are teased out. 

The Daily Mail uses a combination of our survey 
data and a story it ran earlier this year to focus on 
the trading of drugs into the Eurozone. It says that 
one in 10 pharmacists, "as well as wholesalers, 
dispensing doctors and even NHS hospitals - are 
making money from an export trade worth an 
estimated £360 million a year". 

The Scotsman, on the other hand, focuses much 
more on how the lack of branded medicines is 
"hitting patients hard". The Scottish national 
focuses on our statistic that a third of pharmacists 
know a patient whose health had suffered as a 
result of difficulty sourcing a medicine, and that 
the shortage was predicted to get worse next year. 

But moving away from how the story has been 
covered, it's worth looking at what other 
industries would do. In any other retail supply 
chain, these sorts of shortages would be 
intolerable and could drive retailers out of 
business. And in any other supply chain, retailers 
would be able to switch suppliers if goods 
weren't available. 

But pharmacists are being held over a barrel - 
there is often only one supplier of a life-saving 
drug. And if the drug is in short supply, there is 
very little UK pharmacy can do. 

So what is the answer? Is there any solution 
industry leaders have missed? Do you have a 
suggestion that could resolve the stock crisis? Let 
me know your thoughts. 
Niall Hunt is C+D's digital content editor; 
email him at 

Last week's top stories 
on C+D's website 

1. Clinical debate: We can't afford wait in STI war 

30 Ch jgeist 11.09.10 

CD obs 

The place to find your perfect job 

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pharmacy sector 


Beclometasone + formoterol 


ionate and formoterol fumarate dihydrate) pressurised 



inhalation solutioi 
Prescribing Information 

(Refer to Summary of Product Characteristics before prescribing). 
Presentations: Pressurised inhalation solution containing 100 micrograms of 
beclometasone dipropionate and 6 micrograms of formoterol fumarate dihydrate per 
actuation. Indications: Regular treatment of asthma where use ot a combination 
product (inhaled corticosteroid and long-acting beta 2 -agonist) is appropriate: patients 
not adequately controlled with inhaled corticosteroids and 'as needed' inhaled 
short-acting beta 2 agonist; or patients already adequately controlled on both inhaled 
corticosteroids and long-acting beta 2 -agonists. Not appropriate for treatment of acute 
asthma attacks. Dosage and Administration: For inhalation use only. Fostair is 
not intended for the initial management of asthma. If an individual patient should 
require a combination of doses other than those available in the combination inhaler, 
appropriate doses of beti-agonists and/or corticosteroids by individual inhalers should 
be prescribed. Adults: one or two inhalations twice daily, maximum four inhalations 
daily. Not recommended for patients under 1 8 years. Beclometasone dipropionate 
in Fostair is characterised by an extra-fine particle size distribution which results in 
a more potent effect than formulations of beclometasone dipropionate with a non 
extra-fine particle size distribution (100 micrograms of beclometasone dipropionate 
extra-fine in Fostair are equivalent to 250 micrograms of beclometasone dipropionate 
in a ncn extra-fine formulation). Therefore the total daily dose of beclometasone 
dipropionate administered in Fostair should be lower than the total daily dose of 
beclometasone dipropionate administered in a non-extra-fine beclometasone 
dipropionate formulation. Fostair may be used with the AeroChamber Plus™ spacer 
device. Patients' should be advised in the proper use and care of their inhaler and 
spacer. Contraindications: Hypersensitivity to any of the components. Precautions: 
Cardiovascular disorders including cardiac arrhythmias, thyrotoxicosis, diabetes 
mellitus, ' phaeochromocytoma, untreated hypokalemia, pulmonary infections 
(tuberculosis^ fungal or viral). Fostair should not be used as the first treatment for 
asthma, should not be initiated during an exacerbation, or during significantly 
worsening or acutely deteriorating asthma, and should not be stopped abruptly. If 
patients find the treatment ineffective medical attention must be sought. Systemic 

effects of inhaled corticosteroids may occur, particularly at high doses prescribed for 
long periods. These effects are much less likely to occur with inhaled than with oral 
corticosteroids. Possible systemic effects include Cushing's syndrome, Cushingoid 
features, adrenal suppression, decrease in bone mineral density, growth retardation in 
children and adolescents, cataract and glaucoma. Titrate to the lowest dose at which 
effective control of asthma is maintained to minimise systemic effects. Special care 
is needed in transferring patients from oral steroids. Fostair contains a small amount 
of ethanol (approximately 7mg per actuation); at normal doses the amount of ethanol 
is negligible and does not pose a risk to patients. Patients should rinse mouth after 
inhalation to minimise risk of oropharyngeal Candida infection. Drug interactions: 
Beclometasone dipropionate undergoes a very rapid metabolism via esterase 
enzymes without involvement of the cytochrome p450 system. Avoid beta-blockers 
(including eye drops). Caution is required when theophylline or other beta-adrenergic 
drugs are prescribed concomitantly with formoterol. Concomitant treatment with 
quinidine, disopyramide, procainamide, phenothiazines, antihistamines, MAOIs and 
TCAs can prolong the QTc interval and increase the risk of ventricular arrhythmias. 
In addition, L-dopa, L-thyroxine, oxytocin and alcohol can impair cardiac tolerance. 
Concomitant administration with MAOIs, including agents with similar properties such 
as furazolidone and procarbazine, may precipitate hypertension. Risk of arrhythmias 
in patients receiving anaesthesia with halogenated hydrocarbons. Theoretical potential 
for interaction in sensitive patients taking disulfiram or metronidazole. Pregnancy 
and Lactation: No experience. Balance risks with benefits. Side effects: Common: 
pharyngitis, headache, dysphonia. Uncommon: influenza, oral fungal infection 
pharyngeal and oesophageal candidiasis, vaginal candidiasis, gastroenteritis 
sinusitis, granulocytopenia, dermatitis allergic, hypokalaemia, hyperglycaemia 
restlessness, tremor, dizziness, otosalpingitis, cardiac arrhythmias, hyperaemia 
flushing, rhinitis, cough, productive cough, throat irritation, asthmatic crisis, pruritus 
. rash, hyperhidrosis, diarrhoea, dry mouth, dyspepsia, dysphagia, burning sensation of 
the lips, nausea, dysgeusia, muscle spasms, myalgia, Crreactive protein increased 
platelet count increased, free fatty acids increased, blood insulin increased, blood 
ketone body increased. Rare: ventricular extrasystoles, angina pectoris, paradoxical 
bronchospasm, urticaria, angioneurotic oedema, nephritis, blood pressure i 
blood pressure decreased. Very 
adrenal suppression, abnormal 

cataract, atrial fibrillation, dyspnoea, exacerbation of asthma, growth retardation 
in children and adolescents, peripheral oedema, bone density decreased. Legal 
Category: POM Packs and Prices: Fostair 100/6 PL08829/01 56) £29.32. Each 
inhaler contains 120 actuations. Full prescribing information is available from the 
Marketing Authorisation Holder Chiesi Limited, Cheadle Royal Business Park, 
Highfield, Cheadle, SK8 3GY. Date of preparation: July 201 0. 


1 . De Backer W, Devolder A, Poli G et al. Lung deposition of BDP/formoterol HFA 
pMDI in healthy volunteers, asthmatic and COPD patients. J Aerosol Med Pulm 
Drug Deliv 2010; 23(3): 137-148. 

2. Selroos 0, Pietinalho A, Riska H. Delivery devices for inhaled asthma medication. 
Clin Immunother 1996; 6: 273-299. 

3. Fabbri LM, Nicolini G, Olivieri D et al. Inhaled beclometasone dipropionate/ 
formoterol extra-fine fixed combination in the treatment of asthma: evidenc'e 
and future perspectives. Expert Opin Pharmacother 2008; 9: 479-490. 

4. Tulic MK, Hamid Q. New insights into the pathophysiology of the small airways 
in asthma. Clin Chest Med 2006; 27: 41-52. 

5. Huchon G, Magnussen H, Chuchalin A et al. Lung function and asthma contra 
with beclomethasone and formoterol in a single inhaler. Respir Med 2009 ; 1 03 : 

AeroChamber Plus™ is a licensed trademark of Trudell Medical Internation 
Date of preparation: JULY 2010 1 Job code: CHFOS20100392 


Adverse events should be reported. 
Reporting forms and information can be found at 
Adverse events should also be reported to Chiesi Limited (address as above